Neurodevelopmental profile of siblings with Angelman syndrome due to pathogenic UBE3A variants.

BACKGROUND: Angelman syndrome (AS) is a neurodevelopmental disorder caused by a lack of expression of the maternally inherited UBE3A gene on chromosome 15. Individuals with AS due to a UBE3A mutation are more likely to have siblings who also have AS compared with those with AS due to other cytogenetic/molecular mechanisms, but it is unknown whether the developmental outcome of siblings who have AS is similar. METHODS: Through an ongoing AS Natural History Study, we identified seven pairs of siblings with AS due to a UBE3A mutation. We compared the neurodevelopment of the first-born and second-born siblings with AS participants who have a UBE3A mutation and have either typically developing siblings or no siblings. RESULTS: Second-born AS participants due to a UBE3A mutation were more likely to be diagnosed at an earlier age. With the exception of higher expressive language scores among the second-born participants, no other differences were observed in the developmental and adaptive functioning skills across the different groups. CONCLUSIONS: The presence of an older sibling with the same neurodevelopmental disorder is associated with an earlier age of diagnosis and may be associated with an improvement in expressive language skills; the developmental outcome of siblings with AS due to a UBE3A mutation is otherwise comparable.

Pyrethroid and carbamate resistance in Australian Helicoverpa armigera (Lepidoptera: Noctuidae) from 2008 to 2015: what has changed since the introduction of Bt cotton?

Pyrethroid and carbamate resistance was evaluated in Helicoverpa armigera from 2008 to 2015. Insects were collected as eggs primarily from cultivated hosts in the major cropping areas of New South Wales and Queensland, Australia. Larvae reared from eggs were tested for resistance to fenvalerate, bifenthrin or methomyl in the F0 generation using a topical application of a discriminating dose of insecticide. In 2008-2009, resistance to fenvalerate was 71% and no resistance to bifenthrin was recorded. In the following two seasons, resistance to pyrethroids was relatively stable with fenvalerate resistance ranging from 63% to 67% and bifenthrin resistance ranging from 5.6% and 6.4% in 2009-2010 and 2010-2011, respectively. However, in 2011-2012, pyrethroid resistance had increased to 91% and 36% for fenvalerate and bifenthrin, respectively. Resistance remained above 90% for fenvalerate and above 35% for bifenthrin in the following three seasons from 2012 to 2015. In 2008-2009, methomyl resistance was 33% and declined to 22% and 15% in 2009-2010 and 2010-2011, respectively. Methomyl resistance remained at moderate levels from 2011-12 to 2014-15, ranging from 21% to 40%. Factors that influenced selection pressure of pyrethroid and carbamate insecticides and impacted resistance frequency in H. armigera may have been associated with changes in the composition of the cropping landscape. The rapid expansion of the pulse industry and the commensurate increased use of insecticide may have played a role in reselection of high-level pyrethroid resistance, and highlights the need for an urgent and strategic response to insecticide resistance management in the Australian grains industry.

An audit of antimicrobial prescribing by dental practitioners in the north east of England and Cumbria.

BACKGROUND: Inappropriate prescribing of antimicrobials is a significant threat to global public health. In England, approximately 5% of all antimicrobial items are prescribed by dentists, despite the limited indications for their use in the treatment of oral infections in published clinical guidelines. The objective of this study was to survey antimicrobial prescribing by dental practitioners in North East England and Cumbria, identify educational and training needs and develop a self-assessment tool that can be used for Continued Professional Development by individual practitioners. METHODS: During October 2016, 275 dental practitioners used a standardised form to record anonymous information about patients who had been prescribed antimicrobials. Clinical information and prescribing details were compared against clinical guidelines published by the Faculty of General Dental Practitioners UK. RESULTS: Dental practitioners provided data on 1893 antimicrobial prescriptions. There was documented evidence of systemic spread, such as pyrexia in 18% of patients. Dentists recorded patients' pain (91.1% of patients), local lymph gland involvement (41.5%) gross diffuse swelling (55.5%) dysphagia (7.2%) and trismus (13.6%). Reasons for prescribing antimicrobials included patient expectations (25.8%), patient preference (24.8%), time pressures (10.9%), and patients uncooperative with other treatments (10.4%). The most commonly prescribed antimicrobials were amoxicillin, accounting for 61.2% of prescriptions, followed by metronidazole (29.9%). Most prescriptions for amoxicillin were for either 5 days (66.8%) or 7 days (29.6%) and most prescriptions for metronidazole were for a 5-day course (65.2%) or 7-day (18.6%) course. CONCLUSION: In most cases, when an antimicrobial was prescribed, practitioners used the correct choice of agents and usually prescribed these at the correct dose. However, some evidence of suboptimal prescribing practices when compared to the Faculty of General Dental Practitioner guidelines were identified. The audit has identified training needs across the region and aided the development of Continued Professional Development sessions. Further work to identify barriers and facilitators for improving antimicrobial prescribing and determining appropriate methods to improve clinical practice are required.

Alpha-thalassemia intellectual disability: variable phenotypic expression among males with a recurrent nonsense mutation - c.109C>T (p.R37X).

Alpha-thalassemia intellectual disability, one of the recognizable X-linked disability syndromes, is characterized by short stature, microcephaly, distinctive facies, hypotonic appearance, cardiac and genital anomalies, and marked skewing of X-inactivation in female carriers. With the advent of next generation sequencing, mutations have been identified that result in less severe phenotypes lacking one or more of these phenotypic manifestations. Here we report five unrelated kindreds in which a c.109C>T (p.R37X) mutation segregates with a variable but overall milder phenotype. The distinctive facial appearance of alpha-thalassemia intellectual disability was present in only one of the 18 affected males evaluated beyond the age of puberty, although suggestive facial appearance was present in several during infancy or early childhood. Although the responsible genetic alteration is a nonsense mutation in exon 2 of ATRX, the phenotype appears to be partially rescued by the production of alternative transcripts and/or other molecular mechanisms.

X-linked situs abnormalities result from mutations in ZIC3.

Vertebrates position unpaired organs of the chest and abdomen asymmetrically along the left-right (LR) body axis. Each structure comes to lie non-randomly with respect to the midline in an overall position designated situs solitus, exemplified in humans by placement of the heart, stomach and spleen consistently to the left. Aberrant LR axis development can lead to randomization of individual organ position (situs ambiguus) or to mirror-image reversal of all lateralized structures (situs inversus). Previously we mapped a locus for situs abnormalities in humans, HTX1, to Xq26.2 by linkage analysis in a single family (LR1) and by detection of a deletion in an unrelated situs ambiguus male (Family LR2; refs 2,3). From this chromosomal region we have positionally cloned ZIC3, a gene encoding a putative zinc-finger transcription factor. One frameshift, two missense and two nonsense mutations have been identified in familial and sporadic situs ambiguus. The frameshift allele is also associated with situs inversus among some heterozygous females, suggesting that ZIC3 functions in the earliest stages of LR-axis formation. ZIC3, which has not been previously implicated in vertebrate LR-axis development, is the first gene unequivocally associated with human situs abnormalities.

On the performance of a hierarchically porous Ag2S-CuxS electrode in Li-ion batteries.

A new binder- and carbon-free electrode for lithium-ion batteries was prepared using a hierarchically porous Ag-based current collector. The latter was produced by applying the method of selective dissolution of the less noble metals from the Cu60Ag30Al10 master alloy tape. The current collector was reaction-coated with an electrochemically active Ag2S-CuxS coating. The metallic structure provided a mechanically stable conductive scaffold on the walls of which the Ag2S-CuxS skin material was directly deposited. The ordered porosity - hierarchical and directional - provided easy penetration of the liquid electrolyte as well as short Li+ ion diffusion paths. The as-prepared electrodes were tested in a half-cell configuration vs. Li/Li+ at various current rates to study the cycling and rate performances of the electrode. The first cycling capacity of ∼1250 mA h g-1 was measured at 0.4 A g-1 current rate. After a rapid decrease, a stable reversible capacity of ∼230 mA h g-1 was established at a current rate of 0.4 A g-1 (calculated vs. the weight of the incorporated sulphur). Excellent charge/discharge cycling and rate properties were observed for over 1000 cycles at higher rates of 1.0 and 2.0 A g-1, in the potential window of 0.15-2.8 V vs. Li/Li+. The observed cycling stability was ascribed to the mechanism of a "displacement" reaction with Li ions. Additional capacity is also available from alloying-dealloying with Ag (and Cu to some extent) and S redox reactions. These results open up a new opportunity for using a Cu-Ag alloy as the precursor for making electrodes for thin Li-ion and Li-S batteries with high cycling stability at relatively high current rates.

Controlling Cotton's Insect Pests: A New System.

Cotton is more heavily treated with insecticides than any other crop in the United States. In southern Texas, this heavy treatment resulted in insecticide- resistant strains of major pests which almost destroyed the industry in the late 1960's and early 1970's. An integrated insect control program based on new short-season cotton varieties and traditional cultural practices has restored production in the area. The new system has been widely implemented because it produces greater net returns by reducing the use of insecticides, fertilizer, and irrigation.

Development, validity and reliability testing of the East Midlands Evaluation Tool (EMET) for measuring impacts on trainees' confidence and competence following end of life care training.

OBJECTIVES: To develop, test and validate a versatile questionnaire, the East Midlands Evaluation Tool (EMET), for measuring effects of end of life care training events on trainees' self-reported confidence and competence. METHODS: A paper-based questionnaire was designed on the basis of the English Department of Health's core competences for end of life care, with sections for completion pretraining, immediately post-training and also for longer term follow-up. Preliminary versions were field tested at 55 training events delivered by 13 organisations to 1793 trainees working in diverse health and social care backgrounds. Iterative rounds of development aimed to maximise relevance to events and trainees. Internal consistency was assessed by calculating interitem correlations on questionnaire responses during field testing. Content validity was assessed via qualitative content analysis of (1) responses to questionnaires completed by field tester trainers and (2) field notes from a workshop with a separate cohort of experienced trainers. Test-retest reliability was assessed via repeat administration to a cohort of student nurses. RESULTS: The EMET comprises 27 items with Likert-scaled responses supplemented with questions seeking free-text responses. It measures changes in self-assessed confidence and competence on 5 subscales: communication skills; assessment and care planning; symptom management; advance care planning; overarching values and knowledge. Test-retest reliability was found to be good, as was internal consistency: the questions successfully assess different aspects of the same underlying concept. CONCLUSIONS: The EMET provides a time-efficient, reliable and flexible means of evaluating effects of training on self-reported confidence and competence in the key elements of end of life care.

Helicases: a unifying structural theme?

The recent structure determinations of PcrA DNA helicase, NS3 RNA helicase, and Rep DNA helicase have revealed similarities between their folds. When these data are examined with sequence and biochemical analyses, as well as microscopy studies of hexameric helicases, a picture of a unifying structure and mechanism for all helicases is beginning to emerge.

Microarray based comparative genomic hybridization testing in deletion bearing patients with Angelman syndrome: genotype-phenotype correlations.

BACKGROUND: Angelman syndrome (AS) is a neurodevelopmental disorder characterised by severe mental retardation, dysmorphic features, ataxia, seizures, and typical behavioural characteristics, including a happy sociable disposition. AS is caused by maternal deficiency of UBE3A (E6 associated protein ubiquitin protein ligase 3A gene), located in an imprinted region on chromosome 15q11-q13. Although there are four different molecular types of AS, deletions of the 15q11-q13 region account for approximately 70% of the AS patients. These deletions are usually detected by fluorescence in situ hybridisation studies. The deletions can also be subclassified based on their size into class I and class II, with the former being larger and encompassing the latter. METHODS: We studied 22 patients with AS due to microdeletions using a microarray based comparative genomic hybridisation (array CGH) assay to define the deletions and analysed their phenotypic severity, especially expression of the autism phenotype, in order to establish clinical correlations. RESULTS: Overall, children with larger, class I deletions were significantly more likely to meet criteria for autism, had lower cognitive scores, and lower expressive language scores compared with children with smaller, class II deletions. Children with class I deletions also required more medications to control their seizures than did those in the class II group. CONCLUSIONS: There are four known genes (NIPA1, NIPA2, CYFIP1, & GCP5) that are affected by class I but not class II deletions, thus raising the possibility of a role for these genes in autism as well as the development of expressive language skills.

The Use of F2 Screening for Detection of Resistance to Emamectin Benzoate, Chlorantraniliprole, and Indoxacarb in Australian Populations of Helicoverpa armigera (Lepidoptera: Noctuidae).

The ability to effectively detect changes in susceptibility to insecticides is an integral component of resistance management strategies and is highly dependent upon precision of methods deployed. Between 2013 and 2016, F2 screens were performed for detection of resistance alleles in Helicoverpa armigera (Hübner) to emamectin benzoate, chlorantraniliprole, and indoxacarb in major cropping regions of eastern Australia. Resistance to emamectin benzoate was not detected. There were low but detectable levels of survival at discriminating concentrations of chlorantraniliprole and indoxacarb. Alleles conferring an advantage to chlorantraniliprole were present at a frequency of 0.0027 (95% CI 0.0012-0.0064; n = 1,817). Alleles conferring an advantage to indoxacarb were present at a frequency of 0.027 (95% CI 0.020-0.035; n = 1,863). Complementation tests for allelism in six of seven positive indoxacarb tests indicated that resistance was due to alleles present at the same locus. The majority (88%) of lines that tested positive for indoxacarb resistance deviated from a model of recessive inheritance. Pheromone-caught male moths contributed significantly greater numbers of F2 lines compared with moths derived from field-collected eggs or larvae. There was no difference in the detectability of indoxacarb resistance in F2 lines from pheromone-caught moths compared with moths derived from immature stages collected from the field and reared to adult under laboratory conditions. Therefore, we recommend the use of pheromone traps for sourcing insects for F2 screening as a more cost- and time-efficient alternative to traditional methods of sampling.

Oral health promotion in the community pharmacy: an evaluation of a pilot oral health promotion intervention.

Introduction Poor oral health is a significant public health concern, costing the NHS in England £3.4 billion annually. Community pharmacies are easily accessible, frequently visited by patients and the community pharmacy contractual framework requires pharmacies to provide healthy living advice to patients - therefore offering a little explored avenue for the delivery of oral health interventions.Methodology A pilot oral health promotion intervention was introduced in five pharmacies in deprived areas of County Durham between September and December 2016. A mixed methods approach to the evaluation was performed, utilising a patient evaluation questionnaire and semi-structured qualitative interviews with pharmacy staff.Results One thousand and eighty-nine participants received the intervention. Following the intervention 72% of participants perceived their knowledge of oral health as much better, 66% definitely intended to change their oral health habits and 64% definitely thought a pharmacy was the right place to receive advice about oral health. Three themes emerged from the qualitative data: (1) intervention feedback, (2) knowledge gap and (3) service development.Discussion The data demonstrated the acceptability of patients to a community pharmacy based oral health intervention, with most patients reporting intentions to change their oral healthcare habits after receiving the intervention. Previous literature has identified a willingness of pharmacy staff to become involved with oral health; this study provides evidence that patients are also receptive to such services being delivered in the community pharmacy setting. Further work is required to assess the benefits of a community pharmacy based oral health intervention and the potential for further growth of this role.Conclusion A community pharmacy is perceived by patients as an acceptable provider of oral health interventions and has the potential to provide positive changes to the oral health of the population.

Microbial communities and organic biomarkers in a Proterozoic-analog sinkhole.

Little Salt Spring (Sarasota County, FL, USA) is a sinkhole with groundwater vents at ~77 m depth. The entire water column experiences sulfidic (~50 µM) conditions seasonally, resulting in a system poised between oxic and sulfidic conditions. Red pinnacle mats occupy the sediment-water interface in the sunlit upper basin of the sinkhole, and yielded 16S rRNA gene clones affiliated with Cyanobacteria, Chlorobi, and sulfate-reducing clades of Deltaproteobacteria. Nine bacteriochlorophyll e homologues and isorenieratene indicate contributions from Chlorobi, and abundant chlorophyll a and pheophytin a are consistent with the presence of Cyanobacteria. The red pinnacle mat contains hopanoids, including 2-methyl structures that have been interpreted as biomarkers for Cyanobacteria. A single sequence of hpnP, the gene required for methylation of hopanoids at the C-2 position, was recovered in both DNA and cDNA libraries from the red pinnacle mat. The hpnP sequence was most closely related to cyanobacterial hpnP sequences, implying that Cyanobacteria are a source of 2-methyl hopanoids present in the mat. The mats are capable of light-dependent primary productivity as evidenced by 13 C-bicarbonate photoassimilation. We also observed 13 C-bicarbonate photoassimilation in the presence of DCMU, an inhibitor of electron transfer to Photosystem II. Our results indicate that the mats carry out light-driven primary production in the absence of oxygen production-a mechanism that may have delayed the oxygenation of the Earth's oceans and atmosphere during the Proterozoic Eon. Furthermore, our observations of the production of 2-methyl hopanoids by Cyanobacteria under conditions of low oxygen and low light are consistent with the recovery of these structures from ancient black shales as well as their paucity in modern marine environments.

Oculocerebrocutaneous syndrome: the brain malformation defines a core phenotype.

BACKGROUND: Oculocerebrocutaneous syndrome (OCCS) is characterised by orbital cysts and anophthalmia or microphthalmia, focal aplastic or hypoplastic skin defects, skin appendages, and brain malformations. The eye and skin abnormalities are well described but the neuropathological features less so. To date, 28 patients with an unequivocal diagnosis of OCCS have been reported, with a preponderance of males. OBJECTIVE: To evaluate the brain imaging studies, clinical records, photographs, and pathological material of two new and nine previously reported cases of OCCS. RESULTS: There was a consistent pattern of malformations in eight of the 11 cases, consisting of frontal predominant polymicrogyria and periventricular nodular heterotopia, enlarged lateral ventricles or hydrocephalus, agenesis of the corpus callosum sometimes associated with interhemispheric cysts, and a novel mid-hindbrain malformation. The latter consisted of a giant and dysplastic tectum, absent cerebellar vermis, small cerebellar hemispheres in most cases, and a large posterior fossa fluid collection. CONCLUSIONS: The mid-hindbrain malformation appears pathognomonic for OCCS. The eye and skin features of OCCS show considerable overlap with several other syndromes, such as encephalocraniocutaneous lipomatosis, oculo-auriculo-vertebral spectrum, and focal dermal hypoplasia, none of which has a comparable pattern of brain malformations. In particular the unique mid-hindbrain malformation also distinguishes OCCS from related syndromes with comparable forebrain anomalies. The pattern of malformation described thus helps in differentiating OCCS from other entities. The mid-hindbrain malformation points to a defect of the mid-hindbrain organiser as the underlying pathogenic mechanism.

Susceptibility of Helicoverpa armigera (Lepidoptera: Noctuidae) to Cyantraniliprole Determined From Topical and Ingestion Bioassays.

The use of insect bioassay to establish baseline susceptibility and monitor changes in sensitivity to insecticides over time has been a key component of resistance management of Helicoverpa armigera Hübner in Australia for over 30 yr. Cyantraniliprole is a recently introduced insecticide, where toxicity is mediated at the ryanodine receptor. Baseline susceptibility of H. armigera to cyantraniliprole was determined in both topical and ingestion assays performed on field populations collected primarily from commercial farms across eastern Australia. Intraspecific variation in cyantraniliprole susceptibility amongst field strains was 9.3-fold in topical bioassays ( n = 23 strains) and 2.6-fold in ingestion bioassays ( n = 31 strains). The median lethal concentration in field strains was 28 mg/liter in topical bioassays and 0.065 mg/liter in ingestion bioassays, demonstrating that cyantraniliprole was >400-fold more toxic when administered orally than by contact. The narrow range of intraspecific tolerance, high slope values, goodness-of-fit to the probit binomial model, and enhanced toxicity in diet incorporation bioassays compared with topical bioassays suggest that delivery by ingestion is an effective laboratory method for measuring the dose-response of cyantraniliprole in H. armigera . A discriminating dose of 1.5 mg of cyantraniliprole per liter of diet was calculated from diet incorporation bioassays, as a first step in resistance management of cyantraniliprole in Australia.

Treatment of canine nasopharyngeal stenosis using balloon-expandable metallic stents: long-term follow-up of four cases.

Four dogs were diagnosed with nasopharyngeal stenosis using endoscopy and magnetic resonance imaging. Treatment using balloon-expandable metallic stent, placed under fluoroscopic and endoscopic guidance, resulted in immediate resolution of clinical signs. All dogs were clinically normal 40 to 62 months following stent placement.

The Bacillus stearothermophilus replicative helicase: cloning, overexpression and activity.

As part of biochemical and structural studies of the primosome of a gram positive bacterial species, we describe the cloning of the Bacillus stearothermophilus replicative helicase, DnaB. The protein is 45% and 82% identical to the Escherichia coli and B. subtilis replicative helicases, respectively. Recombinant DnaB was purified and shown to be an active helicase.

Cloning, expression, and purification of Bacillus stearothermophilus DNA primase and crystallization of the zinc-binding domain.

The dnaG gene encoding DNA primase has been isolated from chromosomal DNA of Bacillus stearothermophilus and its entire nucleotide sequence determined. The deduced amino acid sequence comprised 597 amino acid residues and the molecular mass was calculated to be 67068 Da. B. stearothermophilus primase was overexpressed in Escherichia coli and purified to homogeneity. The N-terminal 12 kDa zinc-binding domain has been crystallized. The crystals are of the monoclinic space group P21 with cell dimensions a=36 A, b=59 A, c=46 A, beta=91.8 degrees and diffract to 1.7 A resolution.

Structural mechanisms of drug resistance for mutations at codons 181 and 188 in HIV-1 reverse transcriptase and the improved resilience of second generation non-nucleoside inhibitors.

Mutations at either Tyr181 or Tyr188 within HIV-1 reverse transcriptase (RT) give high level resistance to many first generation non-nucleoside inhibitors (NNRTIs) such as the anti-AIDS drug nevirapine. By comparison second generation inhibitors, for instance the drug efavirenz, show much greater resilience to these mutations. In order to understand the structural basis for these differences we have determined a series of seven crystal structures of mutant RTs in complexes with first and second generation NNRTIs as well as one example of an unliganded mutant RT. These are Tyr181Cys RT (TNK-651) to 2.4 A, Tyr181Cys RT (efavirenz) to 2.6 A, Tyr181Cys RT (nevirapine) to 3.0 A, Tyr181Cys RT (PETT-2) to 3.0 A, Tyr188Cys RT (nevirapine) to 2.6 A, Tyr188Cys RT (UC-781) to 2.6 A and Tyr188Cys RT (unliganded) to 2.8 A resolution. In the two previously published structures of HIV-1 reverse transcriptase with mutations at 181 or 188 no side-chain electron density was observed within the p66 subunit (which contains the inhibitor binding pocket) for the mutated residues. In contrast the mutated side-chains can be seen in the NNRTI pocket for all seven structures reported here, eliminating the possibility that disordering contributes to the mechanism of resistance. In the case of the second generation compounds efavirenz with Tyr181Cys RT and UC-781 with Tyr188Cys RT there are only small rearrangements of either inhibitor within the binding site compared to wild-type RT and also for the first generation compounds TNK-651, PETT-2 and nevirapine with Tyr181Cys RT. For nevirapine with the Tyr188Cys RT there is however a more substantial movement of the drug molecule. We conclude that protein conformational changes and rearrangements of drug molecules within the mutated sites are not general features of these particular inhibitor/mutant combinations. The main contribution to drug resistance for Tyr181Cys and Tyr188Cys RT mutations is the loss of aromatic ring stacking interactions for first generation compounds, providing a simple explanation for the resilience of second generation NNRTIs, as such interactions make much less significant contribution to their binding.

Validation of a prototype DiodeAir for small field dosimetry.

Standard commercial diode detectors over-respond within small radiation fields, an effect largely attributable to the relatively high mass-density of silicon. However, Monte Carlo studies can be used to optimise dosimeter designs and have demonstrated that 'mass-density compensation'-for example, introducing a low-density air-gap upstream of a diode's high-density silicon volume-can substantially improve instrument response. In this work we used egs_chamber Monte Carlo simulations to predict the ideal air-gap thickness for a PTW 60017 unshielded diode detector. We then developed a prototype instrument incorporating that air-gap and, for a 6 MV linac, tested it experimentally against EBT3 film. We also tested a further three prototypes with different air-gap thicknesses. Our results demonstrate that for a 10 × 10 cm(2) reference field the DiodeAir, a PTW 60017 diode with a built-in air-gap of 1 mm, has on-axis correction factors near unity. Laterally the DiodeAir performs very well off-axis and reports FWHM and penumbra values consistent with those measured using EBT3. For PDD measurement, the performance of the DiodeAir matches that of the original PTW 60017. The experimental focus of this work was 6 MV but we also simulated the on-axis response of the DiodeAir within 15 MV beams and found that our modification proved robust to this substantial increase in beam energy. However, the original diode 60017 does exhibit low energy scatter dependencies and may over-respond to high linac dose-rates such that applying the mass-density compensation method to an alternative instrument (particularly a diamond detector) could ultimately take us even closer to the small-field ideal.