Rare germline heterozygous missense variants in BRCA1-associated protein 1, BAP1, cause a syndromic neurodevelopmental disorder.

Nuclear deubiquitinase BAP1 (BRCA1-associated protein 1) is a core component of multiprotein complexes that promote transcription by reversing the ubiquitination of histone 2A (H2A). BAP1 is a tumor suppressor whose germline loss-of-function variants predispose to cancer. To our knowledge, there are very rare examples of different germline variants in the same gene causing either a neurodevelopmental disorder (NDD) or a tumor predisposition syndrome. Here, we report a series of 11 de novo germline heterozygous missense BAP1 variants associated with a rare syndromic NDD. Functional analysis showed that most of the variants cannot rescue the consequences of BAP1 inactivation, suggesting a loss-of-function mechanism. In T cells isolated from two affected children, H2A deubiquitination was impaired. In matching peripheral blood mononuclear cells, histone H3 K27 acetylation ChIP-seq indicated that these BAP1 variants induced genome-wide chromatin state alterations, with enrichment for regulatory regions surrounding genes of the ubiquitin-proteasome system (UPS). Altogether, these results define a clinical syndrome caused by rare germline missense BAP1 variants that alter chromatin remodeling through abnormal histone ubiquitination and lead to transcriptional dysregulation of developmental genes.

Injection site number and outcomes of intradetrusor onabotulinumtoxinA for refractory overactive bladder syndrome: a randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: The optimal number of onabotulinumtoxinA injections for the treatment of refractory overactive bladder syndrome is unknown. Our primary objective was to determine whether 10-injections sites with 100 units of onabotulinumtoxinA each were associated with less pain than 20-injections sites. METHODS: In a single-blinded randomized trial, 100 units of onabotulinumtoxinA was administered, either as 10 × 1 ml or as 20 × 0.5 ml injections following the instillation of 30 ml of bupivacaine and 5 ml of NaHCO3 solution for 15 min. The primary outcome was procedural pain, as measured on an 11-point Numerical Pain Rating Scale (NPRS) immediately following the procedure. A power calculation estimated that 16 subjects in each arm were needed to detect a mean difference of 1 with a standard deviation of 1, on the NPRS score between the two treatment groups, with α 0.05 and power 80%. To adjust for an estimated 20% dropout rate, the final sample size was planned for 20 patients per group. RESULTS: From October 2020 to November 2022, a total of 56 patients were approached and 40 were enrolled and randomized to two groups (21 in the 10-injections group and 19 in 20-injections group). The difference in the median pain score between the group was not statistically significant (4 [1.5-5] for 10 injections vs 3 [1-4] for 20 injections, p=0.823). CONCLUSION: Patients' perception of pain, efficacy, and adverse events did not significantly differ between patients receiving 10 and those receiving 20 injections of 100 units of onabotulinumtoxinA.

An Innovative Approach to a Multitrack Advance Practice Registered Nurse Program: The Integration of Psychiatric Mental Health and Primary Care Cohorts.

ABSTRACT: We describe how an online graduate nurse practitioner program combined psychiatric mental health nurse practitioner and primary care advanced practice registered nurse (AGNP/FNP/PNP) tracks into an integrated curriculum. Student evaluations and assessments, along with board certification scores, demonstrated improvement in identifying and managing behavioral health problems, as well as increased competence and collaboration with other nurse practitioner students. Details of the integrated curriculum are provided.

Establishing interprofessional clinical learning experiences in primary care safety-net sites.

This paper describes an interprofessional clinical learning experience for students within two primary care safety-net sites. An interprofessional team of faculty at one university partnered with two safety-net systems to provide students opportunities to work in an interprofessional team providing care for socially and medically complex patients. Our evaluation outcomes are student-centered, focusing on students' perceptions of caring for medically underserved populations and satisfaction with the clinical experience. Students reported positive perceptions of the interprofessional team, clinical experience, primary care, and caring for underserved populations. Strategic development of partnerships between academic and safety-net systems to offer learning opportunities can increase future healthcare providers' exposure and appreciation for interprofessional care of underserved populations.

Robotic-assisted ureteral reimplantation and psoas hitch after ureteral injury during cesarean section.

INTRODUCTION AND HYPOTHESIS: Ureteral injury during gynecological surgery can be managed in a variety of ways, from endoscopic stent placement to ureteroneocystotomy with accompanying psoas hitch and/or Boari flap. The majority of these occur during hysterectomy; therefore, gynecologic surgeons may not be as familiar with repair in women with intact uteri. Herein we present our technique for delayed robotic-assisted ureteral reimplant and psoas hitch in a woman with a ureteral injury sustained during cesarean section, which initially presented as a uretero-cervical fistula. METHODS: In this video, we describe the evaluation and surgical management of a patient with delayed recognition of a left distal ureteral injury sustained during cesarean section. We present necessary modifications to robotic-assisted laparoscopic ureteroneocystostomy and psoas hitch to accommodate an intact uterus including the need for uterine manipulation, division of the round ligament, bladder mobilization from the lower uterine segment and development of the retropubic space, reimplantation steps, and psoas hitch. CONCLUSIONS: Simple modifications to a traditional technique of robotic-assisted ureteroneocystotomy effectively compensate for the presence of a uterus. Obstetricians should maintain a high index of suspicion for ureteral injury in women with new-onset severe urinary leakage post-cesarean section.

Learning speech-internal cues to pronoun interpretation from co-speech gesture: a training study.

This study explores whether children can learn a structural processing bias relevant to pronoun interpretation from brief training. Over three days, 42 five-year-olds were exposed to narratives exhibiting a first-mentioned tendency. Two characters were introduced, and the first-mentioned was later described engaging in a solo activity. In our primary condition of interest, the Gesture Training condition, the solo-activity sentence contained an ambiguous pronoun, but co-speech gesture clarified the referent. There were two comparison conditions. In the Gender Training condition the characters were different genders, thereby avoiding ambiguity. In the Name Training condition, the first-mentioned name was simply repeated. Ambiguous pronoun interpretation was tested pre- and post-training. Children in the Gesture condition were significantly more likely to interpret ambiguous pronouns as the first-mentioned character after training. Results from the comparison conditions were ambiguous: there was a small but non-significant effect of training, but also no significant differences between conditions.

Population representation among anatomical donors and the implication for medical student education.

Dissection provides a unique opportunity to integrate anatomical and clinical education. Commonly, cadavers are randomly assigned to courses, which may result in skewed representation of patient populations. The primary aim of this study was to determine if the anatomical donors studied by students at the University of Massachusetts Medical School (UMMS) accurately represent the disease burden of the local patient population. This cross-sectional study compared the University of Massachusetts Memorial Medical Center patient claims data and body donation data from the UMMS Anatomical Gift Program (AGP). This study examined age, race, sex, and morbidities within a 10-year timeframe in 401,258 patients and 859 anatomical donors who met inclusion criteria. An independent t test was conducted to compare the mean ages of the two populations. Chi square analysis was conducted on race, sex, and 10 morbidity categories. A Fischer's exact test was conducted for two morbidity categories with n < 10. Demographic analysis showed a significant difference in age, and racial representation between the populations. No statistical difference was found regarding sex. Morbidities were separated into 22 ICD-10 categories. Twelve categories were excluded and 10 were analyzed for population comparison. Two categories were over represented and seven were under-represented in the AGP population. One category showed no significant difference between populations. Targeted selection of cadavers in anatomy courses would improve morbidity variability in the anatomy lab. In addition, AGP acceptance guidelines should be evaluated to increase disease variation among the donor population. Clin. Anat. 31:250-258, 2018. © 2017 Wiley Periodicals, Inc.

Thermostable group II intron reverse transcriptase fusion proteins and their use in cDNA synthesis and next-generation RNA sequencing.

Mobile group II introns encode reverse transcriptases (RTs) that function in intron mobility ("retrohoming") by a process that requires reverse transcription of a highly structured, 2-2.5-kb intron RNA with high processivity and fidelity. Although the latter properties are potentially useful for applications in cDNA synthesis and next-generation RNA sequencing (RNA-seq), group II intron RTs have been difficult to purify free of the intron RNA, and their utility as research tools has not been investigated systematically. Here, we developed general methods for the high-level expression and purification of group II intron-encoded RTs as fusion proteins with a rigidly linked, noncleavable solubility tag, and we applied them to group II intron RTs from bacterial thermophiles. We thus obtained thermostable group II intron RT fusion proteins that have higher processivity, fidelity, and thermostability than retroviral RTs, synthesize cDNAs at temperatures up to 81°C, and have significant advantages for qRT-PCR, capillary electrophoresis for RNA-structure mapping, and next-generation RNA sequencing. Further, we find that group II intron RTs differ from the retroviral enzymes in template switching with minimal base-pairing to the 3' ends of new RNA templates, making it possible to efficiently and seamlessly link adaptors containing PCR-primer binding sites to cDNA ends without an RNA ligase step. This novel template-switching activity enables facile and less biased cloning of nonpolyadenylated RNAs, such as miRNAs or protein-bound RNA fragments. Our findings demonstrate novel biochemical activities and inherent advantages of group II intron RTs for research, biotechnological, and diagnostic methods, with potentially wide applications.

The AP-1 transcription factor Batf controls T(H)17 differentiation.

Activator protein 1 (AP-1, also known as JUN) transcription factors are dimers of JUN, FOS, MAF and activating transcription factor (ATF) family proteins characterized by basic region and leucine zipper domains. Many AP-1 proteins contain defined transcriptional activation domains, but BATF and the closely related BATF3 (refs 2, 3) contain only a basic region and leucine zipper, and are considered to be inhibitors of AP-1 activity. Here we show that Batf is required for the differentiation of IL17-producing T helper (T(H)17) cells. T(H)17 cells comprise a CD4(+) T-cell subset that coordinates inflammatory responses in host defence but is pathogenic in autoimmunity. Batf(-/-) mice have normal T(H)1 and T(H)2 differentiation, but show a defect in T(H)17 differentiation, and are resistant to experimental autoimmune encephalomyelitis. Batf(-/-) T cells fail to induce known factors required for T(H)17 differentiation, such as RORgamma t (encoded by Rorc) and the cytokine IL21 (refs 14-17). Neither the addition of IL21 nor the overexpression of RORgamma t fully restores IL17 production in Batf(-/-) T cells. The Il17 promoter is BATF-responsive, and after T(H)17 differentiation, BATF binds conserved intergenic elements in the Il17a-Il17f locus and to the Il17, Il21 and Il22 (ref. 18) promoters. These results demonstrate that the AP-1 protein BATF has a critical role in T(H)17 differentiation.

Investigations into Outbreaks of Black Fly Attacks and Subsequent Avian Haemosporidians in Backyard-Type Poultry and Other Exposed Avian Species.

In late spring of 2009 and 2010, there were reports of severe black fly (Simulium spp., shown in Fig. 1) outbreaks in various counties in Mississippi, especially those in and around the Mississippi River Delta. Complaints were of black flies attacking multiple species of backyard poultry and causing high morbidity and mortality in affected flocks. At several affected locations, black flies were readily observed swarming around and feeding on birds. A large number of these parasites were easily trapped on fly strips (Fig. 2). Multifocal to coalescing cutaneous hemorrhagic lesions, consistent with fly bites, were seen on the birds. Upon necropsy examination, a large number of black flies were also observed in the digestive tract (Fig. 3). Although black flies may cause disease directly, such as cardiopulmonary collapse and anaphylactoid reactions, detection of Leucocytozoon in blood smears (Fig. 4) of affected birds prompted further investigations of this protozoan as a cause of disease. Leucocytozoon spp. are known to be transmitted by black flies and may be associated with morbidity and mortality in birds such as poultry. From June 2009 through July 2012, the investigation included a total collection of 1068 individual blood samples, representing 371 individual premises in 89 counties/parishes across Mississippi (59), Alabama (10), Louisiana (4), and Tennessee (16). Of the 371 premises where blood samples were collected, 96 (26%) were either positive or highly suspected to be positive for Leucocytozoon spp. by blood smear analysis, and 5 (1.2%) were positive for Haemoproteus spp. by blood smear analysis. Attempts to diagnose Leucocytozoon spp. by PCR analysis and sequencing were complicated by coinfections with two closely related haemosporidians (Haemoproteus spp. and Plasmodium spp.). A novel technique involving flow cytometry was also explored. This study discusses the black fly field outbreak, the involvement of haemosporidians, molecular methods for detection of both the black flies and blood parasites, and initial attempts at flow cytometry.

Children's use of gesture in ambiguous pronoun interpretation.

This study explores whether children can use gesture to inform their interpretation of ambiguous pronouns. Specifically, we ask whether four- to eight-year-old English-speaking children are sensitive to information contained in co-referential localizing gestures in video narrations. The data show that the older (7-8 years of age) but not younger (4-5 years) children integrate co-referential gestures into their interpretation of pronouns. This is the same age at which they show sensitivity to order-of-mention, the only other cue available in the stimuli. Interestingly, when children show sensitivity to the gestures, they are quite similar to adults, in that gestures consistent with order-of-mention increase first-mentioned responses as compared to stimuli with no gestures, but only slightly, while gestures inconsistent with order-of-mention have a larger effect on interpretation, decreasing first-mentioned responses and increasing second-mentioned responses.

Overexpression of a BAHD acyltransferase, OsAt10, alters rice cell wall hydroxycinnamic acid content and saccharification.

Grass cell wall properties influence food, feed, and biofuel feedstock usage efficiency. The glucuronoarabinoxylan of grass cell walls is esterified with the phenylpropanoid-derived hydroxycinnamic acids ferulic acid (FA) and para-coumaric acid (p-CA). Feruloyl esters undergo oxidative coupling with neighboring phenylpropanoids on glucuronoarabinoxylan and lignin. Examination of rice (Oryza sativa) mutants in a grass-expanded and -diverged clade of BAHD acyl-coenzyme A-utilizing transferases identified four mutants with altered cell wall FA or p-CA contents. Here, we report on the effects of overexpressing one of these genes, OsAt10 (LOC_Os06g39390), in rice. An activation-tagged line, OsAT10-D1, shows a 60% reduction in matrix polysaccharide-bound FA and an approximately 300% increase in p-CA in young leaf tissue but no discernible phenotypic alterations in vegetative development, lignin content, or lignin composition. Two additional independent OsAt10 overexpression lines show similar changes in FA and p-CA content. Cell wall fractionation and liquid chromatography-mass spectrometry experiments isolate the cell wall alterations in the mutant to ester conjugates of a five-carbon sugar with p-CA and FA. These results suggest that OsAT10 is a p-coumaroyl coenzyme A transferase involved in glucuronoarabinoxylan modification. Biomass from OsAT10-D1 exhibits a 20% to 40% increase in saccharification yield depending on the assay. Thus, OsAt10 is an attractive target for improving grass cell wall quality for fuel and animal feed.

Identification and characterization of microbial biofilm communities associated with corroded oil pipeline surfaces.

Microbially influenced corrosion (MIC) has long been implicated in the deterioration of carbon steel in oil and gas pipeline systems. The authors sought to identify and characterize sessile biofilm communities within a high-temperature oil production pipeline, and to compare the profiles of the biofilm community with those of the previously analyzed planktonic communities. Eubacterial and archaeal 16S rRNA sequences of DNA recovered from extracted pipeline pieces, termed 'cookies,' revealed the presence of thermophilic sulfidogenic anaerobes, as well as mesophilic aerobes. Electron microscopy and elemental analysis of cookies confirmed the presence of sessile cells and chemical constituents consistent with corrosive biofilms. Mass spectrometry of cookie acid washes identified putative hydrocarbon metabolites, while surface profiling revealed pitting and general corrosion damage. The results suggest that in an established closed system, the biofilm taxa are representative of the planktonic eubacterial and archaeal community, and that sampling and monitoring of the planktonic bacterial population can offer insight into biocorrosion activity. Additionally, hydrocarbon biodegradation is likely to sustain these communities. The importance of appropriate sample handling and storage procedures to oilfield MIC diagnostics is highlighted.

Newly modified 'pseudo flap' without compromising vascularity to enhance repair of long distal ureteral loss: A retrospective analysis of a prospective database.

Objective: To present an alternative technique called pseudo-flap for reconstructing long ureteral defects as an alternative to Boari flap. Despite being used for more than 70 years by urologists for tension-free reconstruction of distal and mid-ureteral defects, the Boari flap exhibits high complication rates, with an average of 27% (range 5.5%-30.4%). These complications arise from compromised blood supply, attributed to incisions made on all three sides of the flap and dependence on the flap base as the sole source of blood supply. Methods: We retrospectively reviewed patients who underwent our modified technique by a single surgeon between 2008 and 2021. We used a semi-oblique cystotomy on the lowest part of the anterior and contralateral aspects of the bladder after complete release from adhesions and sacrificing the superior vesical pedicle, if necessary. The innovative part of the technique involved making short relaxing incisions at different levels on both sides of a pseudo-flap while pushing the bladder dome upward to reach the healthy ureter in a tension-free manner, followed by anastomosis with a non-refluxing or refluxing technique. Results: Fifteen patients underwent the pseudo-flap technique with a mean follow-up of 16.9 months. Four had prior radiation, three had hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis, and one had a ureteral stricture in a transplanted kidney. Eight procedures were performed during intraoperative consultations.Only one patient (7%) developed a major complication (Clavien-Dindo grade ≥2). This patient developed postoperative leak, and none developed obstructive hydronephrosis, suggesting stricture or flap ischemia. The mean length of the flap was 9.3 cm. Conclusion: Our pseudo-flap technique has lower complication rates than the traditional Boari flap. It is not technically challenging, minimally compromises blood supply and is thus especially suitable for complex, highly morbid patients with decreased tissue vascularity, such as those with prior radiation and peritoneal carcinomatosis.

Electric-field-enhanced collection of laser-ablated materials onto a solvent bridge for electrospray ionization mass spectrometry.

RATIONALE: Ambient imaging mass spectrometry methods are critically dependent on the ability to efficiently collect all substances from a well-defined area of the sample. Improvements in this area are critical and enabling. METHODS: Methods for the efficient collection of laser-ablated materials directly into a solvent, for immediate transport to an ion source, have been explored using the application of electric fields. RESULTS: Electric-field-enhanced collection of laser-ablated materials has been demonstrated. Demonstrated increases in collection efficiency are as large as two orders of magnitude, in particular for hydrated biological materials, such as living bacterial colonies. This was achieved by applying approximately 1 kV between the sample and the receiving solvent surface. CONCLUSIONS: Electric-field-enhanced collection of laser-ablated materials holds great promise for ambient sampling and imaging mass spectrometry with rapid and direct interfacing to ionization sources, such as electrospray.

Treatment of refractory hemorrhage with Factor XIII in a patient with hemophilia A with inhibitor.

An 11-year-old male with hemophilia A and a known high-titer Factor VIII inhibitor was admitted with retroperitoneal hemorrhage. The patient was receiving infusions of recombinant activated Factor VII (rFVIIa) for a recent elbow hemorrhage when retroperitoneal bleeding commenced. Despite increased dosing of rFVIIa and a dose of activated prothrombin complex concentrate (aPCC), he continued to hemorrhage and required several blood transfusions. Factor XIII was administered 1 hour after rFVIIa and the patient demonstrated cessation of bleeding and normalization of clot strength. Factor XIII may act as an adjuvant in effective clot stabilization in patients with hemophilia and inhibitory antibodies.

Gastroesophageal reflux disease: 2021 guideline updates and clinical pearls.

ABSTRACT: In 2021, the American College of Gastroenterology updated its diagnosis and treatment guideline for gastroesophageal reflux disease (GERD). This article provides a summary of noteworthy changes to the guideline and describes clinical pearls that are pertinent to the diagnosis and treatment of GERD in primary care.

Advancing the Role of the Doctor of Nursing Practice in Palliative Care.

Doctor of nursing practice-prepared nurses are well suited to provide high-quality palliative care to patients with serious illness and their caregivers. Their rigorous education and expertise prepare them for the complexity often associated with chronic disease and end of life. There are clear and strong recommendations from multiple national organizations supporting palliative care education for nurses and tools available for nurses to implement palliative care into practice. This article is from the perspective of the doctor of nursing practice nurse. It reviews the limited evidence on palliative care integration into the doctor of nursing practice role, the barriers to palliative care education and implementing palliative care into practice, and the potential roles that a doctor of nursing practice palliative care nurse may fill in health care.

Artificial infection of the bed bug with Rickettsia parkeri.

Although a variety of disease agents have been reported from bed bugs, the mechanical and biological disease transmission potential of bed bugs remains unelucidated. In this study we assayed survivability of the mildly pathogenic spotted fever group rickettsia, Rickettsia parkeri, in bed bugs after feeding on R. parkeri-infected chicken blood. Two groups of 15 adult bed bugs each were fed on infected or noninfected blood, and two groups of fourth-instar bed bugs also were fed on either infected or noninfected blood. One group of 15 adult bed bugs received no bloodmeal and was included as an additional control. Two weeks postfeeding, two pools of five live bed bugs from each group were surface sterilized, macerated, and placed in Vero cell cultures in an attempt to grow live organism. The remaining five individual bed bugs from each group were dissected, their salivary glands were removed for immunofluorescence assay (IFA) staining, and the remaining body parts were processed for polymerase chain reaction (PCR) analysis. Results indicated that no immature (now molted to fifth instar) bed bugs were positive for R. parkeri by IFA or PCR, indicating that organisms did not survive the molting process. After 4 wk of cell culture, no organisms were seen in cultures from any of the treatment or control groups, nor were any cultures PCR positive. However, two of the adult bed bugs were IFA positive for rickettsia-like organisms, and these two specimens were also PCR positive using R. parkeri-specific primers. These IFA and PCR results indicate that remnants of Rickettsia parkeri (possibly whole organisms) survived in the bugs for 2 wk, but the viability of the organisms in these two specimens could not be determined.

Can online learning adequately prepare medical students to undertake a first female pelvic examination?

OBJECTIVE: To determine whether a novel web-based learning module could adequately prepare first-year undergraduate medical students to skilfully perform their first female pelvic examination. METHODS: First-year Queen's University medical students without prior training or experience in female pelvic examination were recruited for this study. After viewing key segments of the learning module, students were evaluated while performing a pelvic examination on a female volunteer using a standardized assessment checklist (total score = 30 points). Descriptive and comparative statistics were generated. RESULTS: Forty-five students participated with a mean age of 24 years (range 20 to 40). The mean score (±SD) on the assessment checklist was 23.9 ± 3.6 points, (range 17 to 30). All study participants received a passing grade of ≥ 50% (15/30 points), and 53.3% (24/45) received an honours grade of ≥ 80% (24/30 points). Of the participants, 88.9% (40/45) agreed that they were well prepared for their first female pelvic examination after viewing the training video. Mean scores were similar for male students (23.9, n = 22) and female students (23.8, n = 23) (P = 0.90, t test). Mean scores were not higher in those who watched key segments of the learning module more than once. CONCLUSION: This learning module viewed immediately prior to a simulated clinic session afforded first-year medical students the necessary knowledge and skills to perform a first female pelvic examination. This was accomplished with as little as one viewing, and could lead to savings in organizational costs and instruction time for medical school curricula.