The Devil is in the Details: Identifying Aspects of Temperature Variation that Underlie Sex Determination in Species with TSD.

Most organisms experience thermal variability in their environment; however, our understanding of how organisms cope with this variation is under-developed. For example, in organisms with temperature-dependent sex determination (TSD), an inability to predict sex ratios under fluctuating incubation temperatures in the field hinders predictions of how species with TSD will fare in a changing climate. To better understand how sex determination is affected by thermal variation, we incubated Trachemys scripta eggs using a "heat wave" design, where embryos experienced a male-producing temperature of 25 ± 3°C for the majority of development and varying durations at a female-producing temperature of 29.5 ± 3°C during the window of development when sex is determined. We compared the sex ratios from these incubation conditions with a previous data set that utilized a similar heat wave design, but instead incubated eggs at a male-producing temperature of 27 ± 3°C but utilized the same female-producing temperature of 29.5 ± 3°C. We compared the sex ratio reaction norms produced from these two incubation conditions and found that, despite differences in average temperatures, both conditions produced 50:50 sex ratios after ∼8 days of exposure to female-producing conditions. This emphasizes that sex can be determined in just a few days at female-producing conditions and that sex determination is relatively unaffected by temperatures outside of this short window. Further, these data demonstrate the reduced accuracy of the constant temperature equivalent model (the leading method of predicting sex ratios) under thermally variable temperatures. Conceptualizing sex determination as the number of days spent incubating at female-producing conditions rather than an aggregate statistic is supported by the mechanistic underpinnings of TSD, helps to improve sex ratio estimation methods, and has important consequences for predicting how species with TSD will fare in a changing climate.

Patient-level costs in margin re-excision for breast-conserving surgery.

BACKGROUND: High rates of reoperation following breast-conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re-excision costs and compare the direct patient-level costs between patients undergoing successful BCS versus reoperations after BCS. METHODS: The study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient-Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85. RESULTS: The median QHES score was 47 (i.q.r. 32·5-79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234-11786 and $655-9136 respectively. Over a 12-month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752-18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001). CONCLUSION: The systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high-quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.

Short heatwaves during fluctuating incubation regimes produce females under temperature-dependent sex determination with implications for sex ratios in nature.

Patterns of temperature fluctuations in nature affect numerous biological processes, yet, empirical studies often utilize constant temperature treatments. This can limit our understanding of how thermally sensitive species respond to ecologically relevant temperatures. Research on turtles with temperature-dependent sex determination (TSD) provides good examples of this, since nest temperatures from many populations rarely exceed those necessary to produce females under constant laboratory conditions. We hypothesized that exposure to brief periods of warm temperatures (i.e., heat waves) are integral to sex determination in species with TSD, which requires tests that move beyond constant temperatures. We exposed Trachemys scripta embryos from multiple populations and across the nesting season to heat waves of variable durations and quantified sex ratios. We found that embryos from all populations were highly sensitive to brief exposures to female producing temperatures; only 7.9 days of exposure produced a 50:50 sex ratio, but the response varied across the nesting season. From these findings, a model was developed to estimate sex ratios from field temperature traces, and this model outperformed traditional methods. Overall, these results enhance our understanding of TSD and emphasize the importance of using biologically relevant temperatures when studying thermally sensitive processes.

An evaluation of the quality of evidence available to inform current bone conducting hearing device national policy.

OBJECTIVES: In 2016, NHS England published the commissioning policy on Bone Conducting Hearing Devices (BCHDs). This policy was informed by updated evidence on the clinical and cost-effectiveness of BCHDs as well as by the 2013 Bone Anchored Hearing Aid (BAHA) policy. Commissioning policies set the criteria for service delivery and therefore have a major impact on the care received by patients. It is important that stakeholders have a good appreciation of the available evidence informing policy, as this will promote engagement both with the policy and with future research leading on from the policy. In this article, we provide stakeholders with a transparent and pragmatic assessment of the quality of the body of evidence available to inform current BCHD national policy. METHOD: (i) A systematic review of the literature on BCHDs published since the development of the 2013 policy was performed in September 2016, adhering to PRISMA recommendations. The search terms used were as follows bone conduction; bone conducting; bone anchor; BAHA; Bone Anchored Hearing Aid; Bone Conducting Hearing Device; BCHD; Bone Conducting Hearing Implant; BCHI; Sophono; Bonebridge; Soundbite; Ponto; Hearing aid; implant; device; hearing device. Publications that could inform current BCHD policy were included. The quality of included articles was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. (ii) The quality of evidence referenced by the 2013 BAHA policy was assessed using the GRADE system. RESULTS: (i) Of the 2576 publications on BCHDs identified by the systematic search, 39 met the inclusion criteria for further analysis. Using the GRADE criteria, the quality of evidence was classified as of 'very low quality'. (ii) The 2013 BAHA policy was informed by 14 references. The GRADE system classifies the quality of evidence that informed the policy as of 'very low quality'. CONCLUSIONS: The GRADE system defines the body of evidence available to inform current national BCHD policy as of 'very low quality'. There is an urgent need for high-quality research to help make informed policy decisions about the care of patients with hearing loss. An (inter)national registry of BCHDs could address this need.

Cost analysis of the surgical treatment of fractures of the proximal humerus: an evaluation of the determinants of cost and comparison of the institutional cost of treatment with the national tariff.

AIMS: The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost. METHODS: A detailed inpatient treatment pathway was constructed using semi-structured interviews with 32 members of hospital staff. Its content validity was established through a Delphi panel evaluation. Costs were calculated using time-driven activity-based costing (TDABC) and sensitivity analysis was performed to evaluate the determinants of cost RESULTS: The mean cost of the different surgical treatments was estimated to be £3282. Although this represented a profit of £1138 against the national tariff, hemiarthroplasty as a treatment choice resulted in a net loss of £952. Choice of implant and theatre staffing were the largest cost drivers. Operating theatre delays of more than one hour resulted in a loss of income DISCUSSION: Our findings indicate that the national tariff does not accurately represent the cost of treatment for this condition. Effective use of the operating theatre and implant discounting are likely to be more effective cost containment approaches than control of bed-day costs. TAKE HOME MESSAGE: This cost analysis of fractures of the proximal humerus reinforces the limitations of the national tariff within the English National Health Service, and underlines the importance of effective use of the operating theatre, as well as appropriate implant procurement where controlling costs of treatment is concerned.

Temperature experienced during incubation affects antioxidant capacity but not oxidative damage in hatchling red-eared slider turtles (Trachemys scripta elegans).

Our understanding of how oxidative stress resistance phenotypes are affected by the developmental environment is limited. One component of the developmental environment, which is likely central to early life oxidative stress among ectothermic and oviparous species, is that of temperature. We investigated how incubation temperature manipulations affect oxidative damage and total antioxidant capacity (TAC) in red-eared slider turtle (Trachemys scripta elegans) hatchlings. First, to determine whether temperature fluctuations elicit oxidative stress, eggs from clutches were randomly assigned to either a constant (29.5 °C) or daily fluctuating temperature incubation (28.7 ± 3 °C) treatment. Second, to assess the effect of temperature fluctuation frequency on oxidative stress, eggs were incubated in one of three fluctuating incubation regimes: 28.7 ± 3 °C fluctuations every 12 h (hyper), 24 h (normal) or 48 h (hypo). Third, we tested the influence of average incubation temperature by incubating eggs in a daily fluctuating incubation temperature regime with a mean temperature of 26.5 °C (low), 27.1 °C (medium) or 27.7 °C (high). Although the accumulation of oxidative damage in hatchlings was unaffected by any thermal manipulation, TAC was affected by both temperature fluctuation frequency and average incubation temperature. Individuals incubated with a low frequency of temperature fluctuations had reduced TAC, while incubation at a lower average temperature was associated with enhanced TAC. These results indicate that although sufficient to prevent oxidative damage, TAC is influenced by developmental thermal environments, potentially because of temperature-mediated changes in metabolic rate. The observed differences in TAC may have important future consequences for hatchling fitness and overwinter survival.

Turtle hatchlings show behavioral types that are robust to developmental manipulations.

There can be substantial variation among individuals within a species in how they behave, even under similar conditions; this pattern is found in many species and across taxa. However, the mechanisms that give rise to this behavioral variation are often unclear. This study investigated the influence of environmental manipulations during development on behavioral variation in hatchlings of the red-eared slider turtle (Trachemys scripta). First, we examined the effects of three manipulations during incubation (estrone sulfate exposure, corticosterone exposure, and thermal fluctuations) on hatchling righting response and exploration. Second, we determined whether hatchlings showed consistent differences (i.e. behavioral types) in their righting response and exploration across days and months, and whether these behaviors were correlated with one another. Finally, we examined whether righting response was predictive of ecologically relevant behaviors such as habitat choice and dispersal. Hatchling behavior was robust to our early manipulations; none of the pre-hatch treatments affected later behavior. There were significant clutch effects, which due to the split-clutch design suggests genetic underpinnings and/or maternal effects. We found evidence for behavioral types in turtles; both righting response and exploration were strongly repeatable and these behaviors were positively correlated. Righting response was not predictive of dispersal ability in the field, necessitating a revision in the general interpretations of righting response as a proxy for dispersal ability in turtles. Thus, turtle hatchlings show consistent behavioral differences that are robust to early developmental manipulations, and while not necessarily predictive of dispersal, these behavioral types can have important consequences throughout ontogeny.

Are thyroid hormones mediators of incubation temperature-induced phenotypes in birds?

Incubation temperature influences a suite of traits in avian offspring. However, the mechanisms underlying expression of these phenotypes are unknown. Given the importance of thyroid hormones in orchestrating developmental processes, we hypothesized that they may act as an upstream mechanism mediating the effects of temperature on hatchling phenotypic traits such as growth and thermoregulation. We found that plasma T3, but not T4 concentrations, differed among newly hatched wood ducks (Aix sponsa) from different embryonic incubation temperatures. T4 at hatching correlated with time spent hatching, and T3 correlated with hatchling body condition, tarsus length, time spent hatching and incubation period. In addition, the T3 : T4 ratio differed among incubation temperatures at hatch. Our findings are consistent with the hypothesis that incubation temperature modulates plasma thyroid hormones which in turn influences multiple aspects of duckling phenotype.

Thermal challenge severity differentially influences wound healing in wood duck (Aix sponsa) ducklings.

Environmental conditions during early development can profoundly influence an individual's phenotype. Development requires simultaneous maturation and orchestration of multiple physiological systems creating the potential for interaction among key systems and requiring substantial resources. We investigated the influence of thermoregulation on immunocompetence in Wood Duck ducklings (Aix sponsa). At both 1 and 2 days post hatch (dph) we evaluated ducklings' abilities to thermoregulate during a thermal challenge at one of four temperatures (36 [thermoneutral controls], 20, 10, or 5°C). At 3 dph, ducklings received a superficial wound, which was monitored until full recovery to quantify wound healing ability, an ecologically relevant, integrative measure of immune function. We demonstrated that duckling body temperature decreased with increasing thermal challenge severity, thermoregulatory ability increased with age, and thermoregulation had temperature-dependent effects on the immune system. Specifically, a more severe thermal challenge (5°C) resulted in decreased immune performance when compared to a mild challenge (20°C). We conclude that early thermoregulatory experiences are influential in shaping immune responses early in development. Furthermore, our results emphasize that future studies of environmental stressors need to consider multiple physiological endpoints since interaction among systems can result in competing physiological demands.

Incubation conditions are more important in determining early thermoregulatory ability than posthatch resource conditions in a precocial bird.

Recent research in birds suggests that investing in incubation is one mechanism by which parents can enhance the phenotype of their offspring. Posthatch environmental conditions can also shape an individual's phenotype, and it is thus possible for pre- and posthatch conditions to have interactive effects on an individual's phenotype. In this study, we examined the individual and interactive effects of prehatch incubation temperature and posthatch food availability on growth, food consumption, and thermoregulatory ability in wood duck (Aix sponsa) ducklings. Eggs were incubated at one of three temperatures (35.0°, 35.9°, or 37.0°C), and then ducklings were reared on an either ad lib. or time-restricted diet for 12 d after hatching. We found that food availability influenced duckling growth, with the slowest growth occurring in ducklings fed the restricted diet. Incubation temperature also interacted with food conditions to influence duckling growth: ducklings fed ad lib. from the lowest incubation temperature grew slower than ducklings fed ad lib. from the higher incubation temperatures. Most importantly, we found that the improvement in a duckling's ability to maintain body temperature in the face of a thermal challenge was influenced by embryonic incubation temperature but not feeding conditions. Ducklings from the highest incubation temperature experienced the greatest improvement in thermoregulatory performance with age. Our findings suggest that the prehatch environment is more important than posthatch resource conditions in determining some physiological functions and underscores the important role that incubation temperature plays in determining offspring phenotype in birds.

Dual-test monitoring of hyperglycemia using daily glucose and weekly fructosamine values.

The purpose of this study was to assess the impact of using a dual-test blood glucose/fructosamine home monitoring system to assist individuals identified as having the potential for poor glycemic control to achieve values closer to normal. Forty-eight subjects found to have a fasting blood glucose value of > or = 126 mg/dL, casual blood glucose value of > or = 140 mg/dL, and/or blood fructosamine value of > or = 310 micromol/L, agreed to perform daily self testing for 90 days and were provided a dual-test blood glucose/fructosamine home monitoring system and testing supplies at no charge to them. Medication changes/compliance along with dietary and exercise habits were compared to testing results by the principle investigator at approximate 30-day intervals. The desired goal of this project was to achieve and/or maintain a fasting blood glucose value of < or = 110 mg/dL, a casual blood glucose value of < or = 140 mg/dL and a blood fructosamine value of < or = 310 micromol/L by encouraging each individual to realize the effect of dietary intake and exercise habits, and understand the importance of medication compliance, if appropriate, in achieving better overall glycemic control. Four subjects withdrew from the study prior to completion, 11 of the remaining 44 completed 60 days of testing and 33 of 44 completed 90 days of testing. Regular monitoring and counseling achieved an average reduction in blood glucose of 27.5% and a 16.6% reduction in average blood fructosamine when compared to original screening results of these 44 individuals. This study indicates that the addition of weekly fructosamine values to daily blood glucose values provides both the patient and clinician valuable information to evaluate the impact of dietary, exercise, and medication therapy changes on glycemic control by bridging the existing gap between daily blood glucose values and quarterly HbA1c confirmation of intervention results.

Dual test diabetes screening project: screening for poor glycemic control in a large workplace population.

The objective of this study was to assess the efficacy of a dual test blood glucose/fructosamine home monitoring system to screen individuals in the workplace for poor glycemic control. Screening values qualifying individuals for 90 days of additional monitoring were as follows: fasting blood glucose > or =126 mg/dL, casual blood glucose > or =140 mg/dL, and/or fructosamine <310 micromol/L. Subjects with positive values were provided access to classroom instruction by a Certified Diabetes Educator. The population consisted of 100 males and 177 females, ages 22-71 years, mean 49.7 years, with 12 males and 22 females reporting diabetes. Their ethnic backgrounds were 17.7% African American, 0.4% Asian, 1.8% Hispanic, 0.4% mixed, and 79.8% Caucasian reflecting the general United States population. A total of 26 males and 27 females had results indicating poor glycemic control. Of the known individuals with diabetes, seven of 12 males and 15 of 22 females had positive results. More males than females were unaware of their potential for diabetes but of those previously diagnosed with diabetes more females than males had poor glycemic control. A total of 31 subjects tested positive for blood glucose, 39 tested positive for fructosamine, indicating a 15.1% (p < 0.005) improvement in detection chances with fructosamine. Cost per subject including equipment, supplies, and labor was $18.13. Study results indicate that the addition of a fructosamine test improves screening accuracy for large groups of people while retaining ease of use and affordability.

Monoclonal antibodies against Candida tropicalis mannan: antigen detection by enzyme immunoassay and immunofluorescence.

Three strains of mice were immunized with Candida tropicalis cell walls, and antibodies against mannan were detected by indirect enzyme immunoassay (EIA) in 3 of 9 BALB/c mice, 4 of 11 C57BL/6 mice, and 4 of 8 CFW mice. Responding mice produced immunoglobulin M (IgM), but IgG was not detected in their sera. Fusion of the high-responder BALB/c mouse with a plasmacytoma cell line resulted in 41 clones secreting antimannan monoclonal antibodies (MAbs). Four clones selected for propagation included one IgM and one IgG MAb that reacted with mannans of Candida albicans serotypes A and B and of C. tropicalis and two IgM MAbs specific for an epitope only in the mannans of C. albicans serotype A and C. tropicalis. One of the IgM MAbs, CB6, was an effective substitute for rabbit antibodies in the double-antibody sandwich EIA to detect antigenemia produced in rabbits infected with C. albicans A or C. tropicalis. It could function either as the peroxidase-conjugated indicator antibody or as the capture antibody. Two MAbs, CB6 (C. tropicalis and C. albicans A specific) and AC3 (C. tropicalis and C. albicans A and B specific), functioned in place of polyclonal antisera in the serotyping of C. albicans by immunofluorescence. There was 95.8% agreement in the results of serotyping using MAbs as reagents compared with rabbit antisera. Competitive inhibition in EIA between CB6 and monospecific antisera against C. albicans factors 1, 4, and 6 indicated that CB6 binds to an epitope which is probably factor 6. Serologic similarity between factor 4 and the binding site of MAb AC3 was also determined.

Comparison of enzyme immunoassay and gas-liquid chromatography for the rapid diagnosis of invasive candidiasis in cancer patients.

Three proposed quantitative markers for candidiasis, arabinitol, mannose, and mannan in serum, are compared in 50 normal blood donors and 38 high-risk patients, 23 with and 15 without invasive candidiasis. Arabinitol concentrations in serum, the arabinitol/creatinine ratio, and mannose concentrations in serum were significantly greater in the 15 patients without candidiasis than in the normal blood donors (P less than 0.05). The sensitivities and specificities were 26 and 87% for arabinitol, 13 and 93% for the arabinitol/creatinine ratio, and 39 and 87% for mannose. On the other hand, mannan concentrations in serum were less than 1 ng/ml in normal blood donors and patients without candidiasis (P = 0.344), and the sensitivity and specificity were 65 and 100%, respectively. Of 23 patients with proven or probable candidiasis, 16 had mannan levels in serum greater than the mean + 2 standard deviations (0.46 ng/ml) for the 15 controls. In 16 patients with invasive candidiasis and positive blood cultures for the Candida spp., only 13 had elevated levels of at least one of the three markers. The arabinitol/creatinine ratio, the mannose level, and the mannan level became elevated an average of 4 days before, 1 day before, and on the same day that the blood cultures were drawn, respectively. Conversely, mannan was detected in the sera of six of seven patients with invasive candidiasis and negative blood cultures. We conclude that the best approach to diagnosing invasive candidiasis involves obtaining blood cultures and carrying out serial assays for mannan in serum.