Development and Validation of UPLC-MS/MS Analysis for Sphingolipids Isolated from Velvet Antlers of Cervus elaphus.

Deer velvet antlers, known as tonics, have created a large market as dietary supplements and have been consumed worldwide. Despite the high consumption of velvet antlers as dietary supplements, analytical methods for their identification and standardization remain limited. Quantitative analysis for gangliosides, considered quality indexes for velvet antlers, was developed to indirectly analyze the sialic acid obtained from chemical degradation. Owing to the complex and time-consuming chemical derivatization of gangliosides, a simple and rapid quality evaluation method for velvet antlers must be developed. For the first time, this study reports the isolation and structural elucidation of two new sphingomyelins (1 and 2), two known sphingomyelins (3 and 4), and four ceramides (5-8) as chemical markers from the velvet antlers of Cervus elaphus. To expedite and simplify the quality control of velvet antlers, advanced quantitative analysis of sphingolipids has been developed using ultra-performance liquid chromatography-mass spectroscopy.

Sustainability assessment methods for circular bio-based building materials: A literature review.

Using circular bio-based building materials is considered a promising solution to reduce the environmental impacts of the construction industry. To identify the pros and cons of these materials, it is essential to investigate their sustainability performance. However, the previous sustainability assessment studies are heterogeneous regarding the assessment methods and objectives, highlighting the need for a review to identify and analyse these aspects. Moreover, there is still a lack of studies reviewing the methodological issues and implications of the assessment methods, as well as the current end-of-life scenarios and circularity options for these materials. To address these gaps, this study conducts a systematic and critical review of a sample of 97 articles. The results indicate that Life Cycle Assessment (LCA) is the most frequently applied method, yet most studies are cradle-to-gate analyses of materials. Otherwise, very few studies consider the end-of-life phase, and most of the end-of-life scenarios analysed are unsustainable and have low circularity levels. The analysis also highlights the methodological issues of the assessment methods used, with a particular focus on LCA, such as a lack of consensus on system boundaries, functional units, and databases for facilitating sustainability assessments associated with the use of circular bio-based building materials. Two primary recommendations emerge from the analysis. Firstly, for LCA studies, it is recommended to increase transparency and harmonisation in assessments to improve the comparability of results. Besides, to overcome data availability issues, it is recommended to use data from multiple sources and conduct sensitivity and uncertainty analyses. Secondly, more sustainability assessments (including the three pillars) considering the whole life cycle with more sustainable end-of-life scenarios and circularity options for these materials should be conducted.

Desilification of phytolith exacerbates the release of arsenic from rice straw.

Arsenic (As) turnover in rice paddy agro-ecosystems has received much attention because As can enter the food chain through its accumulation in rice, thereby affecting human health. Returning straw to soil is a common practice to retain nutrients for soil and crops, but it also cycles As within the rice paddy field ecosystems. However, there is still a lack of detailed understanding of the fate of As in rice straw, and how or to what extent it is recycled back into the soil environment. This study aims to elucidate the relationship between the microstructure of rice straw and the release of As during rice straw decomposition. The microstructure of rice straw was found to comprise both organic and silica (phytolith) components. These two constituents are inter-embedded to form a composite-like structure that contains up to 6.48 mg As Kg-1. The 30-day batch experiments revealed that the biochemical release of As simultaneously depends upon the decomposition of the organic component and the desilicification of the silica component. Accompanying the release of As was the release of other elements such as Fe, Al, P and S. These elements can further interact with As to form less mobile compounds. The introduction of either Trichoderma harzianum or Bacillus velezensis was expected to accelerate the decomposition of rice straw, and enhance the silica dissolution, hence contributing to an increase in the As release. Despite these expectations, our observations showed the opposite effects. Microorganisms presumably have facilitated the change in solution chemistry or the inclusion of As into the newly-formed precipitates. The biochemical decomposition process can reduce straw particle size, while the negatively-charge surface will involve microsized straw particles in the electrostatic interaction, thereby favoring the dispersibility state. Therefore, the co-transport of micro-sized straw particles with As under field conditions should not be neglected.

Development and validation of the Baseline Recurrence Risk in Cellulitis (BRRISC) score.

OBJECTIVES: Cellulitis is often treated with antibiotics for longer than recommended by guidelines. Prolonged therapy may reduce recurrence in certain patients, but it is not known which patients are at greatest risk. Our objective was to develop and temporally validate a risk prediction score to identify patients attending hospital with cellulitis at highest risk of recurrence. METHODS: We included UK adult patients with cellulitis attending hospital in an electronic health records (EHR) study to identify demographic, comorbid, physiological, and laboratory factors predicting recurrence (before death) within 90 days, using multivariable logistic regression with backwards elimination in complete cases. A points-based risk score integerised model coefficients for selected predictors. Performance was assessed using the C-index in development and temporal validation samples. RESULTS: The final model included 4938 patients treated for median 8 days (IQR 6-11); 8.8% (n = 436) experienced hospitalisation-associated recurrence. A risk score using eight variables (age, heart rate, urea, platelets, albumin, previous cellulitis, venous insufficiency, and liver disease) ranged from 0-15, with C-index = 0.65 (95%CI: 0.63-0.68). Categorising as low (score 0-1), medium (2-5) and high (6-15) risk, recurrence increased fourfold; 3.2% (95%CI: 2.3-4.4%), 9.7% (8.7-10.8%), and 16.6% (13.3-20.4%). Performance was maintained in the validation sample (C-index = 0.63 (95%CI: 0.58-0.67)). Among patients at high risk, four distinct clinical phenotypes were identified using hierarchical clustering 1) young, acutely unwell with liver disease; 2) comorbid with previous cellulitis and venous insufficiency; 3) chronic renal disease with severe renal impairment; and 4) acute severe illness, with substantial inflammatory responses. CONCLUSIONS: Risk of cellulitis recurrence varies markedly according to individual patient factors captured in the Baseline Recurrence Risk in Cellulitis (BRRISC) score. Further work is needed to optimise the score, considering baseline and treatment response variables not captured in EHR data, and establish the utility of risk-based approaches to guide optimal antibiotic duration.

Earthworms can mobilize soil arsenic through their casts.

The mobilization of arsenic (As) in paddy soil has received much attention because it might accelerate the transfer of As from soil to rice. This study aims to elucidate whether earthworms can mobilize As through their casts. Cast samples were collected from 23 different paddy fields in the Red River delta. We first analysed different forms of As through fractionation and then performed batch experiments under reducing conditions to identify factors that govern the mobility of As in casts. Because the dissociation of casts may induce colloids that carry As, the colloidal properties of cast suspensions were also examined. The median value of As in casts (obtained from aqua regia digestion) was 5.11 mg kg-1, which was lower than that in the surrounding soil (6.7 mg kg-1). Compared with the surrounding soil, casts contain less As, possibly because cast As is more labile and more easily lost due to leaching. Various processes, including the reductive dissolution of Fe oxides, decomposition of organic matter, and sorption competition of soluble anionic substances, such as P, Si and DOC, were found to strongly correlate with the release of As from casts. We propose that earthworms, via their casts, may accelerate the As cycle in paddy soils, potentially intensifying As exposure to human health. The dissociation of cast could release colloids containing As; therefore, the cotransport of As with cast-induced colloids should also be considered in future works.

Penicillin Binding Protein Substitutions Cooccur with Fluoroquinolone Resistance in Epidemic Lineages of Multidrug-Resistant Clostridioides difficile.

Clostridioides difficile remains a key cause of healthcare-associated infection, with multidrug-resistant (MDR) lineages causing high-mortality (≥20%) outbreaks. Cephalosporin treatment is a long-established risk factor, and antimicrobial stewardship is a key control. A mechanism underlying raised cephalosporin MICs has not been identified in C. difficile, but among other species, this is often acquired via amino acid substitutions in cell wall transpeptidases (penicillin binding proteins [PBPs]). Here, we investigated five C. difficile transpeptidases (PBP1 to PBP5) for recent substitutions, associated cephalosporin MICs, and co-occurrence with fluoroquinolone resistance. Previously published genome assemblies (n = 7,096) were obtained, representing 16 geographically widespread lineages, including healthcare-associated ST1(027). Recent amino acid substitutions were found within PBP1 (n = 50) and PBP3 (n = 48), ranging from 1 to 10 substitutions per genome. ß-Lactam MICs were measured for closely related pairs of wild-type and PBP-substituted isolates separated by 20 to 273 single nucleotide polymorphisms (SNPs). Recombination-corrected phylogenies were constructed to date substitution acquisition. Key substitutions such as PBP3 V497L and PBP1 T674I/N/V emerged independently across multiple lineages. They were associated with extremely high cephalosporin MICs; 1 to 4 doubling dilutions >wild-type, up to 1,506 µg/mL. Substitution patterns varied by lineage and clade, showed geographic structure, and occurred post-1990, coincident with the gyrA and/or gyrB substitutions conferring fluoroquinolone resistance. In conclusion, recent PBP1 and PBP3 substitutions are associated with raised cephalosporin MICs in C. difficile. Their co-occurrence with fluoroquinolone resistance hinders attempts to understand the relative importance of these drugs in the dissemination of epidemic lineages. Further controlled studies of cephalosporin and fluoroquinolone stewardship are needed to determine their relative effectiveness in outbreak control. IMPORTANCE Fluoroquinolone and cephalosporin use in healthcare settings has triggered outbreaks of high-mortality, multidrug-resistant C. difficile infection. Here, we identify a mechanism associated with raised cephalosporin MICs in C. difficile comprising amino acid substitutions in two cell wall transpeptidase enzymes (penicillin binding proteins). The higher the number of substitutions, the greater the impact on phenotype. Dated phylogenies revealed that substitutions associated with raised cephalosporin and fluoroquinolone MICs were co-acquired immediately before clinically important outbreak strains emerged. PBP substitutions were geographically structured within genetic lineages, suggesting adaptation to local antimicrobial prescribing. Antimicrobial stewardship of cephalosporins and fluoroquinolones is an effective means of C. difficile outbreak control. Genetic changes associated with raised MIC may impart a "fitness cost" after antibiotic withdrawal. Our study therefore identifies a mechanism that may explain the contribution of cephalosporin stewardship to resolving outbreak conditions. However, due to the co-occurrence of raised cephalosporin MICs and fluoroquinolone resistance, further work is needed to determine the relative importance of each.

Photochemical Dimerization of Plakinidine B Leads to Potent Inhibition of the E3 Ubiquitin-Protein Ligase CBL-B.

A new dimeric alkaloid plakoramine A [(±)-1] was identified from a marine sponge Plakortis sp. Chiral-phase HPLC separation of (±)-1 led to the purified enantiomers (+)-1 and (-)-1 which both potently inhibited CBL-B E3 ubiquitin ligase activities. The absolute configurations of the enantiomers were determined by quantum chemical calculations. Scrutinization of the purification conditions revealed a previously undescribed, nonenzymatic route to form (±)-1 via photochemical conversion of its naturally occurring monomeric counterpart, plakinidine B (2).

Longitudinal Median Nerve Ultrasound Changes in Individuals With Spinal Cord Injury and an Age- and Sex-Matched Nondisabled Cohort.

Objectives: To assess the natural history for development of carpal tunnel syndrome (CTS) in persons with acute spinal cord injury (SCI) at 1 year postdischarge from initial rehabilitation and to assess baseline median nerve (MN) cross-sectional area (CSA) above/below 10 mm2 correlates with any longitudinal changes in quantitative ultrasound (US) of the MN. Design: A prospective cohort study of persons with acute SCI evaluated for CTS using quantitative US and compared to a group without SCI (non-SCI). Setting: Academic medical center. Participants: N=69 total (N=34 SCI, N=35 non-SCI). The average age in both groups was 28 and the SCI group included 30 males and 2 females and the non-SCI group included 30 males and 3 females. Interventions: Not applicable. Main Outcome Measures: The primary outcome was the change in quantitative US parameters of the MN, including CSA and grayscale, from baseline to 1-year follow-up in those with SCI and those without SCI. CTS symptomatology and physical exam sum score and US measures for dominant and nondominant arms were considered secondary outcomes. Results: The SCI had darker nerves at baseline (P=.036, nondominant), greater CTS symptoms at follow-up (P≤.036, bilateral), and no differences in all change scores (all P≥.056). Individuals with smaller nerves at baseline had larger increases in nerve size (P=.029, nondominant) vs those with larger nerves. Change in CTS symptoms CSA (nondominant) and nerve echogenicity (dominant) were inversely associated with their respective baseline values (all P≤.045). Conclusions: We observed few differences between the SCI group and the non-SCI control group and between those with smaller vs larger MN. In general, MN pathology changes (CTS symptoms and US variables) over 1 year were more common in the nondominant arm and appear to be a function of MN pathology at enrollment. Individuals with SCI may experience increased CTS symptoms as soon as 1 year after injury.

Creating Computer Vision Models for Respiratory Status Detection.

This study aims to use computers to detect and recognize ventilation objects (masks and tubes) and their positions on the patient's face. We created two models: the You Only Look Once (YOLO) and the Transfer Learning (TL) models, to perform this computer vision task. The development processes and comparison of performance will be described in this paper. The TL model had a better performance (93%) compared to the YOLO model (93%). Clinical Relevance- Healthcare providers and researchers interested in the field of computer vision applied in medicine, specifically automatic object detection using video streams or real-time video streaming may benefit from findings reported.

Genome-wide fetalization of enhancer architecture in heart disease.

Heart disease is associated with re-expression of key transcription factors normally active only during prenatal development of the heart. However, the impact of this reactivation on the regulatory landscape in heart disease is unclear. Here, we use RNA-seq and ChIP-seq targeting a histone modification associated with active transcriptional enhancers to generate genome-wide enhancer maps from left ventricle tissue from up to 26 healthy controls, 18 individuals with idiopathic dilated cardiomyopathy (DCM), and five fetal hearts. Healthy individuals have a highly reproducible epigenomic landscape, consisting of more than 33,000 predicted heart enhancers. In contrast, we observe reproducible disease-associated changes in activity at 6,850 predicted heart enhancers. Combined analysis of adult and fetal samples reveals that the heart disease epigenome and transcriptome both acquire fetal-like characteristics, with 3,400 individual enhancers sharing fetal regulatory properties. We also provide a comprehensive data resource (http://heart.lbl.gov) for the mechanistic exploration of DCM etiology.

The effectiveness of Paraffin oil and Mineral oil for day-5 embryo culture in couples undergoing in vitro fertilisation.

OBJECTIVE: This study evaluated the effectiveness of Paraffin oil versus Mineral oil for day-5 embryo culture in couples undergoing assisted reproductive technology (ART). METHODS: We performed a multi-centre, retrospective cohort study at IVFMD (My Duc Hospital) and IVFMD Phu Nhuan (My Duc Phu Nhuan Hospital) from January 2019 to September 2019. We studied couples treated by intracytoplasmic sperm injection (ICSI), using fresh, ejaculated semen and undergoing day-5 embryo transfer. Couples who underwent in vitro maturation (IVM) or oocyte donation cycles or couples where the woman had uterine abnormalities were excluded. From January 2019 to May 2019, we used Mineral oil (LiteOil, LifeGlobal) while Paraffin oil (Liquid Paraffin, Origio) was used from June 2019 to September 2019. The primary outcome was live birth rate after the first transfer, either from a fresh transfer or frozen embryo transfer. RESULTS: Between 1st January 2019 to 30th September 2019, there were 2,312 couples undergoing ART in both centres, of which 762 (377 in the Paraffin group and 385 in the Mineral group) eligible couples were included in the study. Baseline characteristics of couples were comparable between the two groups, with mean female age 31.5 ± 4.3 versus 31.9 ± 4.7 in the Paraffin and Mineral group. Live birth after the first transfer occurred in 153 (40.6%) couples in the Paraffin group, compared to 152 (39.5%) couples in the Mineral group (risk ratio 1.02, 95% confidence interval 0.91 - 1.14). Other secondary outcomes were comparable between the two groups. CONCLUSION: In day-5 embryo culture, Paraffin and Mineral oil resulted in a comparable live birth rate.

A Community-Based Model of Care During the Fourth Wave of the COVID-19 Outbreak in Ho Chi Minh City, Vietnam.

In response to a call for help during a surge in coronavirus disease-19 (COVID-19) cases in Ho Chi Minh City in July 2021, the University of Medicine and Pharmacy at Ho Chi Minh City developed and implemented a community care model for the management of patients with COVID-19. This was based on three main principles: home care; providing monitoring and care at a distance; and providing timely emergency care if needed. One team supported patients at home with frequent contacts and remote monitoring, while a second team transferred and cared for patients requiring treatment at field emergency care facilities. COVID-19-related mortality rates at the two districts where this approach was implemented (0.43% and 0.57%) were substantially lower than the overall rate in Ho Chi Minh City over the same period (4.95%). Thus, utilization of a community care model can increase the number of patients with COVID-19 who can be effectively managed from home, and use of field emergency care facilities limited the number of patients that had to be referred for tertiary care. Importantly, the community care model also markedly reduced the mortality rate compared with traditional methods of COVID-19 patient management.

Detection of African swine fever virus in neonatal piglets with congenital tremors.

African swine fever virus (ASF) has circulated in Vietnam since 2018, causing significant losses to the pig industry. Quick, accurate diagnosis of African swine fever virus (ASFV) infection is crucial for controlling the disease. The detection of the virus in piglets with congenital tremors is described in this paper. ASFV was detected in brain tissues by polymerase chain reaction (PCR) and immunohistochemistry. Classical swine fever virus, porcine parvovirus, porcine reproductive and respiratory syndrome virus, and pseudorabies virus were not detected by PCR, suggesting that the ASFV was the cause of these neurological signs.

Health record hiccups-5,526 real-world time series with change points labelled by crowdsourced visual inspection.

BACKGROUND: Large routinely collected data such as electronic health records (EHRs) are increasingly used in research, but the statistical methods and processes used to check such data for temporal data quality issues have not moved beyond manual, ad hoc production and visual inspection of graphs. With the prospect of EHR data being used for disease surveillance via automated pipelines and public-facing dashboards, automation of data quality checks will become increasingly valuable. FINDINGS: We generated 5,526 time series from 8 different EHR datasets and engaged >2,000 citizen-science volunteers to label the locations of all suspicious-looking change points in the resulting graphs. Consensus labels were produced using density-based clustering with noise, with validation conducted using 956 images containing labels produced by an experienced data scientist. Parameter tuning was done against 670 images and performance calculated against 286 images, resulting in a final sensitivity of 80.4% (95% CI, 77.1%-83.3%), specificity of 99.8% (99.7%-99.8%), positive predictive value of 84.5% (81.4%-87.2%), and negative predictive value of 99.7% (99.6%-99.7%). In total, 12,745 change points were found within 3,687 of the time series. CONCLUSIONS: This large collection of labelled EHR time series can be used to validate automated methods for change point detection in real-world settings, encouraging the development of methods that can successfully be applied in practice. It is particularly valuable since change point detection methods are typically validated using synthetic data, so their performance in real-world settings cannot be assumed to be comparable. While the dataset focusses on EHRs and data quality, it should also be applicable in other fields.

Classification of Respiratory Conditions using Auscultation Sound.

Management of respiratory conditions relies on timely diagnosis and institution of appropriate management. Computerized analysis and classification of breath sounds has a potential to enhance reliability and accuracy of diagnostic modality while making it suitable for remote monitoring, personalized uses, and self-management uses. In this paper, we describe and compare sound recognition models aimed at automatic diagnostic differentiation of healthy persons vs patients with COPD vs patients with pneumonia using deep learning approaches such as Multi-layer Perceptron Classifier (MLPClassifier) and Convolutional Neural Networks (CNN).Clinical Relevance-Healthcare providers and researchers interested in the field of medical sound analysis, specifically automatic detection/classification of auscultation sound and early diagnosis of respiratory conditions may benefit from this paper.

Antimicrobial resistance in commensal opportunistic pathogens isolated from non-sterile sites can be an effective proxy for surveillance in bloodstream infections.

Antimicrobial resistance (AMR) surveillance in bloodstream infections (BSIs) is challenging in low/middle-income countries (LMICs) given limited laboratory capacity. Other specimens are easier to collect and process and are more likely to be culture-positive. In 8102 E. coli BSIs, 322,087 E. coli urinary tract infections, 6952 S. aureus BSIs and 112,074 S. aureus non-sterile site cultures from Oxfordshire (1998-2018), and other (55,296 isolates) rarer commensal opportunistic pathogens, antibiotic resistance trends over time in blood were strongly associated with those in other specimens (maximum cross-correlation per drug 0.51-0.99). Resistance prevalence was congruent across drug-years for each species (276/312 (88%) species-drug-years with prevalence within ± 10% between blood/other isolates). Results were similar across multiple countries in high/middle/low income-settings in the independent ATLAS dataset (103,559 isolates, 2004-2017) and three further LMIC hospitals/programmes (6154 isolates, 2008-2019). AMR in commensal opportunistic pathogens cultured from BSIs is strongly associated with AMR in commensal opportunistic pathogens cultured from non-sterile sites over calendar time, suggesting the latter could be used as an effective proxy for AMR surveillance in BSIs.

On how the mechanochemical and co-precipitation synthesis method changes the sensitivity and operating range of the Ba2Mg1-xEuxWO6 optical thermometer.

The suitability of Ba2MgWO6 (BMW) double perovskite doped with Eu3+ for the construction of an optical thermometer was tested. It has been shown that by controlling the conditions of BMW synthesis, the sensitivity of the optical thermometer and the useful range of its work can be changed. Pure BMW and doped with Eu3+ samples were prepared using the mechano-chemical and co-precipitation methods. Both the absolute sensitivity and the relative sensitivity in relation to the synthesis route were estimated. The findings proved that the relative sensitivity can be modulated from 1.17%K-1 at 248 K, to 1.5%K-1 at 120 K for the co-precipitation and the mechanochemical samples, respectively. These spectacular results confirm the applicability of the Ba2MgWO6: Eu3+ for the novel luminescent sensors in high-precision temperature detection devices. The density-functional theory was applied to elucidate the origin of the host emission.

Antimicrobial resistance determinants are associated with Staphylococcus aureus bacteraemia and adaptation to the healthcare environment: a bacterial genome-wide association study.

Staphylococcus aureus is a major bacterial pathogen in humans, and a dominant cause of severe bloodstream infections. Globally, antimicrobial resistance (AMR) in S. aureus remains challenging. While human risk factors for infection have been defined, contradictory evidence exists for the role of bacterial genomic variation in S. aureus disease. To investigate the contribution of bacterial lineage and genomic variation to the development of bloodstream infection, we undertook a genome-wide association study comparing bacteria from 1017 individuals with bacteraemia to 984 adults with asymptomatic S. aureus nasal carriage. Within 984 carriage isolates, we also compared healthcare-associated (HA) carriage with community-associated (CA) carriage. All major global lineages were represented in both bacteraemia and carriage, with no evidence for different infection rates. However, kmers tagging trimethoprim resistance-conferring mutation F99Y in dfrB were significantly associated with bacteraemia-vs-carriage (P=10-8.9-10-9.3). Pooling variation within genes, bacteraemia-vs-carriage was associated with the presence of mecA (HMP=10-5.3) as well as the presence of SCCmec (HMP=10-4.4). Among S. aureus carriers, no lineages were associated with HA-vs-CA carriage. However, we found a novel signal of HA-vs-CA carriage in the foldase protein prsA, where kmers representing conserved sequence allele were associated with CA carriage (P=10-7.1-10-19.4), while in gyrA, a ciprofloxacin resistance-conferring mutation, L84S, was associated with HA carriage (P=10-7.2). In an extensive study of S. aureus bacteraemia and nasal carriage in the UK, we found strong evidence that all S. aureus lineages are equally capable of causing bloodstream infection, and of being carried in the healthcare environment. Genomic variation in the foldase protein prsA is a novel genomic marker of healthcare origin in S. aureus but was not associated with bacteraemia. AMR determinants were associated with both bacteraemia and healthcare-associated carriage, suggesting that AMR increases the propensity not only to survive in healthcare environments, but also to cause invasive disease.

Prior Authorization, Copayments, and Utilization of Sacubitril/Valsartan in Medicare and Commercial Plans in Patients With Heart Failure With Reduced Ejection Fraction.

BACKGROUND: Slow uptake of sacubitril/valsartan in patients with heart failure with reduced ejection fraction has been reported, which may negatively impact clinical outcomes. We characterized prior authorization (PA) burden, prescription copayment, and utilization of sacubitril/valsartan by insurance plan type to identify potential barriers to its use. METHODS: We conducted a national population-level, cross-sectional study using PA data from an insurance coverage website accessed in March 2019 and IQVIA National Prescription Audit data from August 2018 to July 2019. Primary outcomes were proportion of plans requiring PA, frequency of specific PA criteria, number of sacubitril/valsartan prescriptions, and copayments per insurance plan type. RESULTS: Overall, 48.1% (1394/2896) of insurance plans required PA for sacubitril/valsartan. Fewer Medicare (27.7%) than commercial (57.2%) plans required PA (P<0.001). For both plan types, the most frequently required PA criteria were ejection fraction (71.6%, 90.9%) and New York Heart Association class (60.4%, 90.8%) for Medicare and commercial plans, respectively. Copayment amounts varied by plan type, with more sacubitril/valsartan prescriptions for commercial plans not requiring a patient copayment (32.4%) compared with Medicare plans (19.3%; P<0.001). There were 814 437 sacubitril/valsartan prescriptions for Medicare and 822 292 for commercial plans dispensed from August 2018 to July 2019. Based on estimated heart failure with reduced ejection fraction populations for each plan type, 4-fold more sacubitril/valsartan prescriptions were dispensed in commercial than in Medicare plans (820 versus 215 prescriptions/1000 individuals in the heart failure with reduced ejection fraction population). The estimated proportion of heart failure with reduced ejection fraction patients prescribed sacubitril/valsartan was 3.6% (1.5%-6.8%) for Medicare and 13.7% (4.9%-31.8%) for commercial plan populations. CONCLUSIONS: Despite commercial plans having greater PA requirements than Medicare, population-adjusted use of sacubitril/valsartan was higher in commercial plans. Given that commercial plans had more prescriptions with low copayments than Medicare, copayment policies may be more influential on sacubitril/valsartan use than its PA policies. Low sacubitril/valsartan use in both plan types highlights the multifactorial nature of medication underutilization that includes factors beyond the drug policies that we evaluated.

Mouse Mandibular Retromolar Taste Buds Associated With a Mucus Salivary Gland.

We have characterized a recently rediscovered chemosensory structure at the rear of the mandibular mucosa in the mouse oral cavity originally reported in the 1980s. This consists of unorganized taste buds, not contained within troughs, associated with the ducts of an underlying minor salivary gland. Using whole-mount preparations of transgenic mice expressing green fluorescent protein under the promoter of taste-signaling-specific genes, we determined that the structure contains taste bud clusters and salivary gland orifices at the rear of each mandible, distal to the last molar and anterior to the ascending ramus. Immunohistochemical analysis shows in the retromolar taste buds expression of the taste receptors Tas2R131 and T1R3 and taste cascade molecules TrpM5, PLCß2, and GNAT3, consistent with type II taste cells, and expression of GAD1, consistent with type III taste cells. Furthermore, the neuronal marker, calcitonin gene-related peptide, in retromolar mucosa tissue wrapping around TrpM5+ taste buds was observed. RT-PCR showed that retromolar taste buds express all 3 mouse tas1r genes, 28 of the 35 tas2r genes, and taste transduction signaling genes gnat3, plcb2, and trpm5, making the retromolar taste buds similar to other lingual and palate taste buds. Finally, histochemistry demonstrated that the mandibular retromolar secretory gland is a minor salivary gland of mucous type. The mandibular retromolar taste structure may thus play a role in taste sensation and represent a potential novel pharmacological target for taste disorders.