Learning curves and association of pathologist's performance with the diagnostic accuracy of linear endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA): a cohort study in a tertiary care reference centre.

OBJECTIVES: We aimed to assess the learning curves and the influence of the pathologist's performance on the endobronchial ultrasound transbronchial needle aspiration's (EBUS-TBNA's) diagnostic accuracy in a real-world study. DESIGN/SETTING: Cohort study conducted in a tertiary care university hospital (single centre) with patients referred for EBUS-TBNA. PARTICIPANTS/INTERVENTION: We initially evaluated 376 patients (673 lymph nodes), 368 (660 lymph nodes) of whom were recruited. The inclusion criterion was EBUS-TBNA indicated for the study of mediastinal or hilar lesions. The exclusion criteria were the absence of mediastinal and hilar lesions during EBUS confirmed by a normal mediastinum and hilum on chest CT (except in cases of mediastinal staging of cancer) and lost to follow-up. PRIMARY AND SECONDARY OUTCOME MEASURES: Diagnostic accuracy and related outcomes. METHODS: We included patients from a prospectively constructed database. We performed a logistic regression multivariate analysis to adjust for potential confounders of the association between pathologist performance and EBUS-TBNA accuracy. The Cumulative Summation (CUSUM) analysis was used to assess pathologists' performance and learning curves. RESULTS: Most indications for EBUS were suspicion of malignancy, including intrathoracic tumours (68.3%), extrathoracic tumours (9.8%) and cancer staging (7.0%). The patients' mean age was 63.7 years, and 71.5% were male. Overall EBUS-TBNA accuracy was 80.8%. In the multivariate logistic regression model, the factors independently associated with EBUS-TBNA accuracy included certain pathologists (ORs ranging from 0.16 to 0.41; p<0.017), a lymph node short-axis diameter <1 cm (OR: 0.36; 95% CI 0.21 to 0.62; p<0.001), and the aetiology of lymph node enlargement (ORs ranging from 7 to 37; p<0.001). CUSUM analysis revealed four different learning curve patterns, ranging from almost immediate learning to a prolonged learning phase, as well as a pattern consistent with performance attrition. CONCLUSIONS: Pathologists' proficiency conditioned EBUS-TBNA accuracy. This human factor is a potential source of error independent of factors conditioning tissue sample adequacy.

SNX27-Retromer directly binds ESCPE-1 to transfer cargo proteins during endosomal recycling.

Coat complexes coordinate cargo recognition through cargo adaptors with biogenesis of transport carriers during integral membrane protein trafficking. Here, we combine biochemical, structural, and cellular analyses to establish the mechanistic basis through which SNX27-Retromer, a major endosomal cargo adaptor, couples to the membrane remodeling endosomal SNX-BAR sorting complex for promoting exit 1 (ESCPE-1). In showing that the SNX27 FERM (4.1/ezrin/radixin/moesin) domain directly binds acidic-Asp-Leu-Phe (aDLF) motifs in the SNX1/SNX2 subunits of ESCPE-1, we propose a handover model where SNX27-Retromer captured cargo proteins are transferred into ESCPE-1 transport carriers to promote endosome-to-plasma membrane recycling. By revealing that assembly of the SNX27:Retromer:ESCPE-1 coat evolved in a stepwise manner during early metazoan evolution, likely reflecting the increasing complexity of endosome-to-plasma membrane recycling from the ancestral opisthokont to modern animals, we provide further evidence of the functional diversification of yeast pentameric Retromer in the recycling of hundreds of integral membrane proteins in metazoans.

Discordant phylogeographic patterns between the tortoise tick Hyalomma aegyptium and their Testudo graeca hosts.

Tortoise ticks, Hyalomma aegyptium, are considered so strongly associated with their hosts that they are even used as indirect indicators for them. In such a case, a robust pattern of congruence between host and parasite could be expected, with phylogeographic breaks within the host being reflected in their parasites. We sequenced two mitochondrial partial gene regions (12S rRNA and Cytochrome Oxidase 1) from ticks across northern Africa and Anatolia, and compared patterns of variation with those identified in its main host, Testudo graeca. Two distinct haplogroups were identified, both of which were found distributed across much of northern Africa. This pattern does not reflect the known variation within the host, which has multiple, geographically disjunct subspecies in this region, but rather the major climatic zones. This relationship can be explained by adaptive processes to environmental conditions influenced by the climate, as well as by the spatial structure of the communities of tick potential hosts in larval and nymphal stages. Extensive anthropogenic movement of tortoises may also obscure congruence patterns between H. aegyptium ticks and their hosts.

Diversity of microorganisms in Hyalomma aegyptium collected from spur-thighed tortoise (Testudo graeca) in North Africa and Anatolia.

Ticks carry a diverse community of microorganisms including non-pathogenic symbionts, commensals, and pathogens, such as viruses, bacteria, protozoans, and fungi. The assessment of tick-borne microorganisms (TBM) in tortoises and their ticks is essential to understand their eco-epidemiology, and to map and monitor potential pathogens to humans and other animals. The aim of this study was to characterize the diversity of microorganisms found in ticks collected from the spur-thighed tortoise (Testudo graeca) in North Africa and Anatolia. Ticks feeding on wild T. graeca were collected, and pathogens were screened by polymerase chain reaction using group-specific primers. In total, 131 adult Hyalomma aegyptium ticks were collected from 92 T. graeca in Morocco (n = 48), Tunisia (n = 2), Algeria (n = 70), and Turkey (n = 11). Bacteria and protozoa detected included Hemolivia mauritanica (22.9%), Midichloria mitochondrii (11.4%), relapsing-fever borreliae (8.4%), Ehrlichia spp. (7.6%), Rickettsia spp. (3.4%), Borrelia burgdorferi s.l. (0.9%), Francisella spp. (0.9%), and Wolbachia spp. (0.8%). The characterization of Rickettsia included R. sibirica mongolitimonae (Algeria), R. aeschlimannii (Turkey), and R.africae (Morocco). Hemolivia mauritanica and Ehrlichia spp. prevalence varied significantly with the sampling region/country. We did not detect significant associations in microorganism presence within ticks, nor between microorganism presence and tick mitochondrial DNA haplogroups. This is the first report of Francisella persica-like, relapsing fever borreliae, M. mitochondrii, and Wolbachia spp. in H. aegyptium ticks collected from wild hosts from the South and Eastern Mediterranean region, and of R. sibirica mongolitimonae and R. africae in H. aegyptium from Algeria and Morocco, respectively. Given that T. graeca is a common species in commercial and non-commercial pet trade, the evaluation of the role of this species and its ticks as hosts for TBM is particularly relevant for public health.

Exceptional stability of a perilipin on lipid droplets depends on its polar residues, suggesting multimeric assembly.

Numerous proteins target lipid droplets (LDs) through amphipathic helices (AHs). It is generally assumed that AHs insert bulky hydrophobic residues in packing defects at the LD surface. However, this model does not explain the targeting of perilipins, the most abundant and specific amphipathic proteins of LDs, which are weakly hydrophobic. A striking example is Plin4, whose gigantic and repetitive AH lacks bulky hydrophobic residues. Using a range of complementary approaches, we show that Plin4 forms a remarkably immobile and stable protein layer at the surface of cellular or in vitro generated oil droplets, and decreases LD size. Plin4 AH stability on LDs is exquisitely sensitive to the nature and distribution of its polar residues. These results suggest that Plin4 forms stable arrangements of adjacent AHs via polar/electrostatic interactions, reminiscent of the organization of apolipoproteins in lipoprotein particles, thus pointing to a general mechanism of AH stabilization via lateral interactions.

Ethanolamine Oleate for Bronchopleural Fistula: Case Series.

BACKGROUND: Bronchopleural fistula (BPF) is a severe complication of pulmonary resection associated with high morbidity and mortality. Treatment options include both surgical and endoscopic procedures. The size of the fistula and the functional status of the patient are decisive factors in the choice of treatment. The aim of this study is to describe the experience of using ethanolamine oleate (EO) in endoscopic treatment for BPFs. METHODS: A prospective observational, descriptive study, involving patients with subcentimeter BPF and treated with EO. The diagnosis of the fistula was confirmed by flexible bronchoscopy. Patients under conscious sedation received a perifistular injection of EO with a Wang 22-G needle. The procedure was repeated every to 2 weeks until definitive closure. RESULTS: Eight patients were included: in 7 (87.5%), the fistula was a complication of lung cancer surgery. The number of sessions needed before the resolution of the BPF was from 1 to 4. Only 1 patient received 4 sessions. Complete closure was obtained in 6 patients (75%). None of the fistulas reopened, and there were no serious complications. CONCLUSION: Sclerosis with EO through endoscopic injection enables the closure of small (<1 cm) BPFs after a limited number of sessions and with scarce morbidity. These results suggest that EO could be a valid treatment option for selected patients.

Sperm storage reduces the strength of the mate-finding Allee effect.

Mate searching is a key component of sexual reproduction that can have important implications for population viability, especially for the mate-finding Allee effect. Interannual sperm storage by females may be an adaptation that potentially attenuates mate limitation, but the demographic consequences of this functional trait have not been studied. Our goal is to assess the effect of female sperm storage durability on the strength of the mate-finding Allee effect and the viability of populations subject to low population density and habitat alteration. We used an individual-based simulation model that incorporates realistic representations of the demographic and spatial processes of our model species, the spur-thighed tortoise (Testudo graeca). This allowed for a detailed assessment of reproductive rates, population growth rates, and extinction probabilities. We also studied the relationship between the number of reproductive males and the reproductive rates for scenarios combining different levels of sperm storage durability, initial population density, and landscape alteration. Our results showed that simulated populations parameterized with the field-observed demographic rates collapsed for short sperm storage durability, but were viable for a durability of one year or longer. In contrast, the simulated populations with a low initial density were only viable in human-altered landscapes for sperm storage durability of 4 years. We find that sperm storage is an effective mechanism that can reduce the strength of the mate-finding Allee effect and contribute to the persistence of low-density populations. Our study highlights the key role of sperm storage in the dynamics of species with limited movement ability to facilitate reproduction in patchy landscapes or during population expansion. This study represents the first quantification of the effect of sperm storage durability on population dynamics in different landscapes and population scenarios.

Impact of habitat loss on the diversity and structure of ecological networks between oxyurid nematodes and spur-thighed tortoises (Testudo graeca L.).

Habitat loss and fragmentation are recognized as affecting the nature of biotic interactions, although we still know little about such changes for reptilian herbivores and their hindgut nematodes, in which endosymbiont interactions could range from mutualistic to commensal and parasitic. We investigated the potential cost and benefit of endosymbiont interactions between the spur-thighed tortoise (Testudo graeca L.) and adult oxyurid nematodes (Pharyngodonidae order Oxyurida) in scrublands of southern Spain. For this, we assessed the association between richness and abundance of oxyurid species with tortoises' growth rates and body traits (weight and carapace length) across levels of habitat loss (low, intermediate and high). Furthermore, by using an intrapopulation ecological network approach, we evaluated the structure and diversity of tortoise-oxyurid interactions by focusing on oxyurid species infesting individual tortoises with different body traits and growth rates across habitats. Overall, tortoise body traits were not related to oxyurid infestation across habitats. Oxyurid richness and abundance however, showed contrasting relationships with growth rates across levels of habitat loss. At low habitat loss, oxyurid infestation was positively associated with growth rates (suggesting a mutualistic oxyurid-tortoise relationship), but the association became negative at high habitat loss (suggesting a parasitic relationship). Furthermore, no relationship was observed when habitat loss was intermediate (suggesting a commensal relationship). The network analysis showed that the oxyurid community was not randomly assembled but significantly nested, revealing a structured pattern for all levels of habitat loss. The diversity of interactions was lowest at low habitat loss. The intermediate level, however, showed the greatest specialization, which indicates that individuals were infested by fewer oxyurids in this landscape, whereas at high habitat loss individuals were the most generalized hosts. Related to the latter, connectance was greatest at high habitat loss, reflecting a more uniform spread of interactions among oxyurid species. At an individual level, heavier and larger tortoises tended to show a greater number of oxyurid species interactions. We conclude that there is an association between habitat loss and the tortoise-oxyurid interaction. Although we cannot infer causality in their association, we hypothesize that such oxyurids could have negative, neutral and positive consequences for tortoise growth rates. Ecological network analysis can help in the understanding of the nature of such changes in tortoise-oxyurid interactions by showing how generalized or specialized such interactions are under different environmental conditions and how vulnerable endosymbiont interactions might be to further habitat loss.

The Many Faces of Amphipathic Helices.

Amphipathic helices (AHs), a secondary feature found in many proteins, are defined by their structure and by the segregation of hydrophobic and polar residues between two faces of the helix. This segregation allows AHs to adsorb at polar⁻apolar interfaces such as the lipid surfaces of cellular organelles. Using various examples, we discuss here how variations within this general scheme impart membrane-interacting AHs with different interfacial properties. Among the key parameters are: (i) the size of hydrophobic residues and their density per helical turn; (ii) the nature, the charge, and the distribution of polar residues; and (iii) the length of the AH. Depending on how these parameters are tuned, AHs can deform lipid bilayers, sense membrane curvature, recognize specific lipids, coat lipid droplets, or protect membranes from stress. Via these diverse mechanisms, AHs play important roles in many cellular processes.

A giant amphipathic helix from a perilipin that is adapted for coating lipid droplets.

How proteins are targeted to lipid droplets (LDs) and distinguish the LD surface from the surfaces of other organelles is poorly understood, but many contain predicted amphipathic helices (AHs) that are involved in targeting. We have focused on human perilipin 4 (Plin4), which contains an AH that is exceptional in terms of length and repetitiveness. Using model cellular systems, we show that AH length, hydrophobicity, and charge are important for AH targeting to LDs and that these properties can compensate for one another, albeit at a loss of targeting specificity. Using synthetic lipids, we show that purified Plin4 AH binds poorly to lipid bilayers but strongly interacts with pure triglycerides, acting as a coat and forming small oil droplets. Because Plin4 overexpression alleviates LD instability under conditions where their coverage by phospholipids is limiting, we propose that the Plin4 AH replaces the LD lipid monolayer, for example during LD growth.

Human-mediated secondary contact of two tortoise lineages results in sex-biased introgression.

Human-mediated secondary contact of recently diverged taxa offers valuable opportunities for studying the evolutionary mechanisms involved in the establishment and maintenance of genetic boundaries between taxa. We used mitochondrial and microsatellite markers to examine a recently introduced population of the spur-thighed tortoise (Testudo graeca) of mixed origin in the Doñana National Park (SW Spain). The earliest records of tortoises in Doñana trace back to the 18th century, but several population reinforcements in the 20th century with animals from Morocco are well-documented. Consequently, different genetic lineages, which represent distinct subspecies, are thought to co-exist there. Our results confirmed the presence of distinct lineages by revealing that tortoises of the subspecies T. g. marokkensis were introduced into a local allochthonous T. g. graeca population. Unexpectedly, T. g. marokkensis haplotypes exclusively appeared in males, and admixture levels were statistically sex-biased toward males. The sex ratio of the population deviated from parity, with males being 2.36-fold more abundant than females. Our results indicated that population reinforcements had a strong effect on the genetic composition of this population and aggravated its sex ratio deviation. We predict that this sex-biased pattern of introgression is ephemeral and advocated to the near loss of T. g. marokkensis haplotypes.

Low tortoise abundances in pine forest plantations in forest-shrubland transition areas.

In the transition between Mediterranean forest and the arid subtropical shrublands of the southeastern Iberian Peninsula, humans have transformed habitat since ancient times. Understanding the role of the original mosaic landscapes in wildlife species and the effects of the current changes as pine forest plantations, performed even outside the forest ecological boundaries, are important conservation issues. We studied variation in the density of the endangered spur-thighed tortoise (Testudo graeca) in three areas that include the four most common land types within the species' range (pine forests, natural shrubs, dryland crop fields, and abandoned crop fields). Tortoise densities were estimated using a two-stage modeling approach with line transect distance sampling. Densities in dryland crop fields, abandoned crop fields and natural shrubs were higher (>6 individuals/ha) than in pine forests (1.25 individuals/ha). We also found large variation in density in the pine forests. Recent pine plantations showed higher densities than mature pine forests where shrub and herbaceous cover was taller and thicker. We hypothesize that mature pine forest might constrain tortoise activity by acting as partial barriers to movements. This issue is relevant for management purposes given that large areas in the tortoise's range have recently been converted to pine plantations.

Direct percutaneous endoscopic jejunostomy in pediatric age with a pexies triangulation system: report of a case and literature review.

Direct percutaneous endoscopic jejunostomy (DPEJ) is an infrequent procedure as it is not always easy to obtain transillumination, being this the main reason for failure of this technique. In patients with previous surgery, this procedure is more complex and there are only 6 reported cases in pediatric population. In our case, we provide the use of an endoscopic triangulation system with "T" pexies not used before in these cases. With this technique, we guarantee not to replace the introduction system afterwards, obtaining the placement of a balloon fixation system initially. We also provide several improvements that helped us developing the procedure: Placement of the jejunostomy through a gastrostomy; use of water column to avoid penetration in hollow viscus; use of a guide wire, and a triangulation pexy system.

Yeyunostomía endoscópica directa en edad pediátrica mediante sistema de triangulación (PEXIA): aportación de un caso y revisión de la literatura / Direct percutaneous endoscopic jejunostomy in pediatric age with a pexies triangulation system: Report of a case and literature review

La yeyunostomía endoscópica directa es una técnica infrecuente pues no siempre es fácil conseguir la transiluminación, motivo por el que se fracasa en su colocación con mayor frecuencia. En pacientes con cirugía previa aún es más compleja, y en la edad pediátrica sólo hay 6 casos publicados en la literatura. Además se aporta la utilización de un sistema de triangulación con pexias en T que no se ha utilizado hasta ahora en esta indicación. De esta forma nos aseguramos el no tener que retirar posteriormente el sistema de introducción, dejando desde el principio un sistema de fijación con balón. Aportamos varias mejoras que nos ayudaron en la técnica: realización a través de la gastrostomía, uso de columna de agua para evitar paso por vísceras huecas, uso de hilo guía y sistema de pexia-triangulación (AU)

Direct percutaneous endoscopic jejunostomy (DPEJ) is an infrequent procedure as it is not always easy to obtain transillumination, being this the main reason for failure of this technique. In patients with previous surgery, this procedure is more complex and there are only 6 reported cases in pediatric population. In our case, we provide the use of an endoscopic triangulation system with "T" pexies not used before in these cases. With this technique, we guarantee not to replace the introduction system afterwards, obtaining the placement of a balloon fixation system initially. We also provide several improvements that helped us developing the procedure: Placement of the jejunostomy through a gastrostomy; use of water column to avoid penetration in hollow viscus; use of a guide wire, and a triangulation pexy system

Surfing in tortoises? Empirical signs of genetic structuring owing to range expansion.

Much of our current knowledge about the genetic dynamics in range expansions originates from models, simulations and microcosm experiments that need to be corroborated by field data. Here, we report a neutral genetic pattern that matches the predictions of the genetic surfing theory. Genetic surfing occurs when repeated founding events and genetic drift act on the wave of advance of an expanding population, promoting strong spatial structure. In the range expansion of the tortoise Testudo graeca from North Africa to southeastern Spain, we found several genetic signatures consistent with surfing: a decrease of genetic diversity with distance from the initial founder area, clinal patterns in allele frequencies, rare African alleles which have become common at distal sites in the Spanish range, and stronger spatial differentiation in the expanded range than in the original one. Our results provide support for the theory that genetic drift can be an important force in shaping the genetic structure of expanding populations.

Differences in helminth infections between captive and wild spur-thighed tortoises Testudo graeca in southern Spain: a potential risk of reintroductions of this species.

Although the spur-thighed tortoise, Testudo graeca, is one of the most widely distributed species of tortoises, its natural populations are threatened through its whole range. Particularly at south-eastern Spain, the species is mainly threatened by habitat destruction and over-collection, given that this chelonian has been traditionally considered an appreciate pet. As south-eastern Spanish wildlife recovery centers shelter hundreds of captive animals mainly coming from illegal trade or captive-bred, there is a strong debate about what to do with these animals: maintaining them in captivity all along their lives or reintroducing them to wildlife. It is well known that the reintroduction of captive animals supposes a risk for the wild population due to the uncertainty of their genetic origin and to the possible spread of infectious diseases. However, despite the increasing evidence that infectious agents are a potential health hazard for wildlife, little is known about the risk that introduced parasites could suppose for the wild populations of spur-thighed tortoise. The present study investigates for the first time the presence of helminth eggs and worms in faeces from 107 wild and captive individuals collected from mid-March to mid-June 2010, and relates the findings to different environmental and host variables. Sixteen oxyurid species and the ascarid Angusticaecum holopterum were identified. This last nematode and the oxyurid species Tachygonetria palearticus and T. seurati had not been reported in Spanish wild T. graeca previously. The prevalence of oxyurid eggs and worms were 94% and 70%, respectively; while, ascarid eggs and worms were found in 26% and 5% of tortoises, respectively. Ascarid infections affected mostly captive animals and were associated to caparace deformities and symptoms of upper respiratory tract disease (p<0.05). Oxyurid infections were not associated to negative health traits and prevalence increased with age. In free-living tortoises, the distribution of pharingodonid genera also varied according to habitat; moreover, T. longicollis, T. pusilla, T. conica, T. robusta and Mehdiella stylosa where significantly more frequent in wild compared to captive tortoises (p<0.05). Study results highlight important differences in the nematode fauna of captive and free-living tortoises and questions one more time if the reintroductions of captive animals suppose a risk for the wild population since the former ones can harbor and distribute among free populations pathogens like ascarid nematodes.

Evaluation of local ecological knowledge as a method for collecting extensive data on animal abundance.

The use of local ecological knowledge (LEK) has been advocated for biodiversity monitoring and management. To date, however, it has been underused in studying wild populations of animals and, particularly, in obtaining quantitative abundance estimates. We evaluated LEK as a tool for collecting extensive data on local animal abundance and population trends. We interviewed shepherds in southeastern Spain, asking them to estimate the local abundance of the terrestrial tortoise Testudo graeca. We quantified reliability of abundance estimates derived from interviews by comparing them with those obtained from standard field-sampling protocols (distance sampling). We also explored the complementarity of these 2 approaches. LEK provided high-quality and low-cost information about both distribution and abundance of T. graeca. Interviews with shepherds yielded abundance estimates in a much wider range than linear transects, which only detected the species in the upper two-thirds of its abundance range. Abundance estimates from both methodologies showed a close relationship. Analysis of confidence intervals indicated local knowledge could be used to estimate mean local abundances and to detect mean population trends. A cost analysis determined that the information derived from LEK was 100 times cheaper than that obtained through linear-transect surveys. Our results should further the use of LEK as a standard tool for sampling the quantitative abundance of a great variety of taxa, particularly when population densities are low and traditional sampling methods are expensive or difficult to implement.