Multivariate classification of multichannel long-term electrophysiology data identifies different sleep stages in fruit flies.

Identifying different sleep stages in humans and other mammals has traditionally relied on electroencephalograms. Such an approach is not feasible in certain animals such as invertebrates, although these animals could also be sleeping in stages. Here, we perform long-term multichannel local field potential recordings in the brains of behaving flies undergoing spontaneous sleep bouts. We acquired consistent spatial recordings of local field potentials across multiple flies, allowing us to compare brain activity across awake and sleep periods. Using machine learning, we uncover distinct temporal stages of sleep and explore the associated spatial and spectral features across the fly brain. Further, we analyze the electrophysiological correlates of microbehaviors associated with certain sleep stages. We confirm the existence of a distinct sleep stage associated with rhythmic proboscis extensions and show that spectral features of this sleep-related behavior differ significantly from those associated with the same behavior during wakefulness, indicating a dissociation between behavior and the brain states wherein these behaviors reside.

Outcomes of Transplantation of Single Kidneys From Pediatric Donors Into Adult Recipients.

Background Organs from extreme ages have been sought after to help increase the donor pool and alleviate transplantation wait times. There has been a growing evolution of the use of pediatric donor kidneys, including the use of en bloc kidneys (EBK), to now separating them into single kidneys (SKT), allowing for transplantation of two recipients. This study reports our outcomes utilizing SKT. Methods A retrospective review of all SKT performed from 2014 to 2022 at our center was conducted. Donors >8 years of age or >25 kg in weight were excluded. Donor and recipient characteristics and outcomes were analyzed, comparing <18 kg and ≥18 kg donor cohorts. Results Between 2014 and 2022, 81 adults received SKT. Recipients' mean age, weight, and body mass index were 49 years (22-74), 74 kg (39-136), and 26.4 mg/m2 (19.6- 39.8), respectively. Donors' mean age, weight, and kidney size were 35.7 months (8-96), 17.8 kg (8-25), and 7.2 cm (4.5-8.5), respectively. At one year post-transplant, patient survival was 100%, graft survival was 98.7%, mean serum creatinine was 1.25 mg/dL, and mean glomerular filtration rate (GFR) was 68.3 ml/min. Hyperfiltration injury was seen in 43.75% of recipients. None of the outcomes correlated with any of the donor or recipient characteristics. Conclusion Our study shows excellent short-term outcomes of single pediatric kidney transplantation in adult recipients. Exploring a lower donor weight cut-off for SKT, compared to the current Organ Procurement and Transplantation Network's (OPTN's) ≥18 kg, could expand the organ pool and lead to an increased number of transplants.

Advancing Data Science Among the Federal Public Health Workforce: The Data Science Upskilling Program, Centers for Disease Control and Prevention.

CONTEXT: Data can guide decision-making to improve the health of communities, but potential for use can only be realized if public health professionals have data science skills. However, not enough public health professionals possess the quantitative data skills to meet growing data science needs, including at the Centers for Disease Control and Prevention (CDC). PROGRAM: The Data Science Upskilling (DSU) program increases data science literacy among staff and fellows working and training at CDC. The DSU program was established in 2019 as a team-based, project-driven, on-the-job applied upskilling program. Learners, within interdisciplinary teams, use curated learning resources to advance their CDC projects. The program has rapidly expanded from upskilling 13 teams of 31 learners during 2019-2020 to upskilling 36 teams of 143 learners during 2022-2023. EVALUATION: All 2022-2023 cohort respondents to the end-of-project survey reported the program increased their data science knowledge. In addition, 90% agreed DSU improved their data science skills, 93% agreed it improved their confidence making data science decisions, and 96% agreed it improved their ability to perform data science work that benefits CDC. DISCUSSION: DSU is an innovative, inclusive, and successful approach to improving data science literacy at CDC. DSU may serve as an upskilling model for other organizations.

"Pre-Histologic" Antibody-Mediated Rejection Detected by Donor-Derived Cell-Free DNA and a Novel Tissue Gene Expression Assay: A Case Report.

BACKGROUND: Despite its well-characterized association with poor long-term graft outcomes, subclinical antibody-mediated rejection (ABMR) in recipients of kidney transplants continues to pose a significant diagnostic and therapeutic challenge. Specifically, its detection currently relies on invasive histologic surveillance, a relatively uncommon practice among US transplant centers. We describe a subclinical, "pre-histologic" antibody-mediated rejection identified and characterized by a combination of novel molecular tools, donor-derived cell-free DNA (dd-cfDNA), and molecular histology. CASE REPORT: A 67-year-old kidney transplant recipient was found to have a marked elevation of dd-cfDNA on routine testing at 3 months post-transplant; other laboratory parameters were stable. A biopsy was performed, demonstrating the absence of rejection by traditional histology, but evidence of rejection was seen when tissue was evaluated using a research use molecular histology assay. Four months later, in the setting of persistently elevated dd-cfDNA, the patient developed graft dysfunction and was found to have C4d-negative ABMR, which was treated with improvement in both graft function and dd-cfDNA. CONCLUSION: This case highlighted the complementary use of dd-cfDNA and molecular histology to aid in the early detection and characterization of graft injury. Hybrid approaches combining these tools may allow more expeditious therapeutic intervention, leading to improved graft and patient outcomes.

Are Proud Tibial Cone Constructs an Effective Alternative to Those That are Fully Seated in Revision Total Knee Arthroplasty?

BACKGROUND: This study compared the clinical, radiographic, and patient-reported outcomes between patients treated with the traditional fully seated tibial cone construct and those with the novel proud tibial cone construct in revision total knee arthroplasty (rTKA). METHODS: This was a retrospective study of 56 adult patients who had a minimum 2-year follow-up and underwent rTKA with either the fully seated (n = 18 knees) or proud (n = 42 knees) tibial cone construct between 2010 and 2020. The electronic medical record was reviewed for demographic, clinical, and radiographic data. Knee Injury and Osteoarthritis Outcome Scores (KOOS) were collected. RESULTS: All patients had improved mechanical alignment postoperatively regardless of surgical technique. All patients showed good evidence of osseointegration without loss of fixation at the latest follow-up. There were no significant differences in the complication rate or re-revision rate between the groups. KOOS Function in Sport and Recreation (Sport/Rec) scores were significantly higher for patients treated with the fully seated construct (mean 57 [range, 20 to 95] versus 38 [range, 0 to 75], P = .04); however, no significant differences were present for the other KOOS subscales or KOOS Jr. CONCLUSION: The proud tibial cone construct may be an effective alternative to the fully seated construct in the setting of severe bone loss in rTKA. The proud construct avoids a proximal tibial cut, and thus is a bone-preserving technique that provides good fixation, reduces operative time, prevents potential iatrogenic injuries, decreases the need for tibial augments, saves costs, and improves the ease of restoring joint height.

Neuraxial Anesthesia in Patients With Aortic Stenosis: A Systematic Review.

Neuraxial anesthesia (NA) has been contraindicated in patients with aortic stenosis (AS) due to concerns of sympathetic blockade and hemodynamic instability. These considerations are based on precautionary expert recommendations, supported by expected physiologic effects, but in the absence of any published scientific evidence. In light of the increasing elderly population and the prevalence of AS, this systematic review compiles available literature on NA in patients with AS to address the understanding of the anesthetic practice and safety in this population. Using a systematic approach, PubMed, Embase, and Web of Science were searched for studies of patients with AS who exclusively received NA. Primary outcomes included intraoperative and postoperative complications. Of 1,433 citations, 61 met full-text inclusion criteria, including 3,228 patients undergoing noncardiac (n = 3,146, 97.5%), obstetric (n = 69, 2.1%), and cardiac (n = 13, 0.4%) procedures. Significant data heterogeneity (local anesthetic dosing, intraoperative interventions, and measured outcomes) prevented formal metanalysis, but descriptive data are presented. Spinal block (n = 2,856, 88.5%) and epidural anesthesia (n = 397, 12.3%) were administered most frequently. Hypotension requiring vasopressors was the most common intraoperative complication-noncardiac (n = 16, 9.9%), obstetric (n = 6, 13.0%), and cardiac (n = 1, 7.7%)-with resolution in all patients and no reported intraoperative cardiovascular collapse or mortality. The relative risk of different AS severities remains unclear, and optimal medication dosing remains elusive. The authors' data suggested that NA may not be contraindicated in carefully selected patients with AS. The authors' results should inform the design of future prospective studies comparing NA and general anesthesia in patients with AS.

The Art and Science of Kidney Transplant Offer Evaluation.

Currently, there are more than 100,000 patients on the transplant waitlist in the United States. There exists a significant gap between the supply and demand for kidney transplants. Despite this, about a quarter of kidneys recovered from deceased donors are not being utilized. There is a significant variation in kidney acceptance criteria by transplant centers. The current kidney allocation system allows transplant centers to place kidneys into appropriate recipients who may not be at the top of the list to increase organ utilization. A recent study questioned this practice of "list diving." In this editorial, we seek to support "list diving" through a discussion of the various factors a transplant center could take into consideration while evaluating organ offers.

Consensus recommendations for the treatment and management of patients with Fabry disease on migalastat: a modified Delphi study.

Objective: Fabry disease is a progressive disorder caused by deficiency of the α-galactosidase A enzyme (α-Gal A), leading to multisystemic organ damage with heterogenous clinical presentation. The addition of the oral chaperone therapy migalastat to the available treatment options for Fabry disease is not yet universally reflected in all treatment guidelines. These consensus recommendations are intended to provide guidance for the treatment and monitoring of patients with Fabry disease receiving migalastat. Methods: A modified Delphi process was conducted to determine consensus on treatment decisions and monitoring of patients with Fabry disease receiving migalastat. The multidisciplinary panel comprised 14 expert physicians across nine specialties and two patients with Fabry disease. Two rounds of Delphi surveys were completed and recommendations on the use of biomarkers, multidisciplinary monitoring, and treatment decisions were generated based on statements that reached consensus. Results: The expert panel reached consensus agreement on 49 of 54 statements, including 16 that reached consensus in round 1. Statements that reached consensus agreement are summarized in recommendations for migalastat treatment and monitoring, including baseline and follow-up assessments and frequency. All patients with Fabry disease and an amenable mutation may initiate migalastat treatment if they have evidence of Fabry-related symptoms and/or organ involvement. Treatment decisions should include holistic assessment of the patient, considering clinical symptoms and organ involvement as well as patient-reported outcomes and patient preference. The reliability of α-Gal A and globotriaosylsphingosine as pharmacodynamic response biomarkers remains unclear. Conclusion: These recommendations build on previously published guidelines to highlight the importance of holistic, multidisciplinary monitoring for patients with Fabry disease receiving migalastat, in addition to shared decision-making regarding treatments and monitoring throughout the patient journey. GRAPHICAL ABSTRACT.

Multivariate classification of multichannel long-term electrophysiology data identifies different sleep stages in fruit flies.

Sleep is observed in most animals, which suggests it subserves a fundamental process associated with adaptive biological functions. However, the evidence to directly associate sleep with a specific function is lacking, in part because sleep is not a single process in many animals. In humans and other mammals, different sleep stages have traditionally been identified using electroencephalograms (EEGs), but such an approach is not feasible in different animals such as insects. Here, we perform long-term multichannel local field potential (LFP) recordings in the brains of behaving flies undergoing spontaneous sleep bouts. We developed protocols to allow for consistent spatial recordings of LFPs across multiple flies, allowing us to compare the LFP activity across awake and sleep periods and further compare the same to induced sleep. Using machine learning, we uncover the existence of distinct temporal stages of sleep and explore the associated spatial and spectral features across the fly brain. Further, we analyze the electrophysiological correlates of micro-behaviours associated with certain sleep stages. We confirm the existence of a distinct sleep stage associated with rhythmic proboscis extensions and show that spectral features of this sleep-related behavior differ significantly from those associated with the same behavior during wakefulness, indicating a dissociation between behavior and the brain states wherein these behaviors reside.

Whole-brain annotation and multi-connectome cell typing quantifies circuit stereotypy in Drosophila.

The fruit fly Drosophila melanogaster combines surprisingly sophisticated behaviour with a highly tractable nervous system. A large part of the fly's success as a model organism in modern neuroscience stems from the concentration of collaboratively generated molecular genetic and digital resources. As presented in our FlyWire companion paper 1 , this now includes the first full brain connectome of an adult animal. Here we report the systematic and hierarchical annotation of this ~130,000-neuron connectome including neuronal classes, cell types and developmental units (hemilineages). This enables any researcher to navigate this huge dataset and find systems and neurons of interest, linked to the literature through the Virtual Fly Brain database 2 . Crucially, this resource includes 4,552 cell types. 3,094 are rigorous consensus validations of cell types previously proposed in the hemibrain connectome 3 . In addition, we propose 1,458 new cell types, arising mostly from the fact that the FlyWire connectome spans the whole brain, whereas the hemibrain derives from a subvolume. Comparison of FlyWire and the hemibrain showed that cell type counts and strong connections were largely stable, but connection weights were surprisingly variable within and across animals. Further analysis defined simple heuristics for connectome interpretation: connections stronger than 10 unitary synapses or providing >1% of the input to a target cell are highly conserved. Some cell types showed increased variability across connectomes: the most common cell type in the mushroom body, required for learning and memory, is almost twice as numerous in FlyWire as the hemibrain. We find evidence for functional homeostasis through adjustments of the absolute amount of excitatory input while maintaining the excitation-inhibition ratio. Finally, and surprisingly, about one third of the cell types proposed in the hemibrain connectome could not yet be reliably identified in the FlyWire connectome. We therefore suggest that cell types should be defined to be robust to inter-individual variation, namely as groups of cells that are quantitatively more similar to cells in a different brain than to any other cell in the same brain. Joint analysis of the FlyWire and hemibrain connectomes demonstrates the viability and utility of this new definition. Our work defines a consensus cell type atlas for the fly brain and provides both an intellectual framework and open source toolchain for brain-scale comparative connectomics.

Gastrointestinal Complications After Transesophageal Echocardiography for Mitral Valve Transcatheter Edge-to-Edge Repair: Insights From a Large Contemporary Cohort.

OBJECTIVES: Transesophageal echocardiography-related complications (TEE-RC) are higher in structural heart interventions than in traditional operative settings. In mitral valve transcatheter edge-to-edge repair (MV-TEER), the incidence of TEE-RC may be higher than in other structural interventions. However, existing reports are limited and robust data evaluating TEE safety in this patient population are lacking. The authors sought to describe the incidence and risk factors of upper gastrointestinal injuries after TEE in patients undergoing MV-TEER. DESIGN: A retrospective observational study. SETTING: A single tertiary academic hospital. PARTICIPANTS: A total of 442 consecutive patients who underwent MV-TEER, specifically with MitraClip, between December 2015 and March 2022. INTERVENTIONS: Transesophageal echocardiography was performed intraoperatively to guide all MV-TEERs. MEASUREMENTS AND MAIN RESULTS: The study's primary goal was to investigate an association between TEE procedure duration and TEE-RC risk. The contribution of demographic risk factors and intraprocedural characteristics also was investigated. Transesophageal echocardiography-RCs were observed in 17 out of 442 patients (3.8%). Dysphagia was the most common TEE-RC (n = 9/17, 53%), followed by new gastroesophageal reflux (n = 6/17, 35%) and odynophagia (n = 3/17, 18%). There were no esophageal perforations or upper gastrointestinal bleeds. History of dysphagia was the only variable associated with TEE-RCs (p = 0.008; n = 9 [2.1%] v n = 3 [18%]), with a relative risk of 8.67 (95% CI 2.57, 29.16). The TEE procedure duration was not statistically different between the 2 groups (46 minutes [39-64] in TEE-RCs v 49 minutes [36-77] in no complications). CONCLUSION: In patients undergoing MV-TEER, TEE-RCs are uncommon, and major complications are rare. The authors' outcomes reflect those of a high-volume referral center with TEEs performed by cardiac anesthesiologists.

Diastolic Left Main Coronary Artery Flow Reversal.

In patients undergoing percutaneous cardiac interventions, perioperative transesophageal echocardiography is used routinely, often revealing an unusual pathology that was not previously detected with transthoracic echocardiography. In this e-challenge, the authors present a patient undergoing percutaneous transcatheter aortic valve replacement, with preprocedural transesophageal echocardiography revealing an abnormal color Doppler signal near the left main coronary artery during diastole.

The First Differentiated TB Care Model From India: Delays and Predictors of Losses in the Care Cascade.

To reduce TB deaths in resource-limited settings, a differentiated care strategy can be used to triage patients with high risk of severe illness (i.e., those with very severe undernutrition, respiratory insufficiency, or inability to stand without support) at diagnosis and refer them for comprehensive assessment and inpatient care. Globally, there are few examples of implementing this type of strategy in routine program settings. Beginning in April 2022, the Indian state of Tamil Nadu implemented a differentiated care strategy called Tamil Nadu-Kasanoi Erappila Thittam (TN-KET) for all adults aged 15 years and older with drug-susceptible TB notified by public facilities. Before evaluating the impact on TB deaths, we sought to understand the retention and delays in the care cascade as well as predictors of losses. During April-June 2022, 14,961 TB patients were notified and 11,599 (78%) were triaged. Of those triaged, 1,509 (13%) were at high risk of severe illness; of these, 1,128 (75%) were comprehensively assessed at a nodal inpatient care facility. Of 993 confirmed as severely ill, 909 (92%) were admitted, with 8% unfavorable admission outcomes (4% deaths). Median admission duration was 4 days. From diagnosis, the median delay in triaging and admission of severely ill patients was 1 day each. Likelihood of triaging decreased for people with extrapulmonary TB, those diagnosed in high-notification districts or teaching hospitals, and those transferred out of district. Predictors of not being comprehensively assessed included: aged 25-34 years, able to stand without support, and diagnosis at a primary or secondary-level facility. Inability to stand without support was a predictor of unfavorable admission outcomes. To conclude, the first quarter of implementation suggests that TN-KET was feasible to implement but could be improved by addressing predictors of losses in the care cascade and increasing admission duration.

--Eleven tips for operational researchers working with health programmes: our experience based on implementing differentiated tuberculosis care in south India.

Due to the workload and lack of a critical mass of trained operational researchers within their ranks, health systems and programmes may not be able to dedicate sufficient time to conducting operational research (OR). Hence, they may need the technical support of operational researchers from research/academic organisations. Additionally, there is a knowledge gap regarding implementing differentiated tuberculosis (TB) care in programme settings. In this 'how we did it' paper, we share our experience of implementing a differentiated TB care model along with an inbuilt OR component in Tamil Nadu, a southern state in India. This was a health system initiative through a collaboration of the State TB cell with the Indian Council of Medical Research institutes and the World Health Organisation country office in India. The learnings are in the form of eleven tips: four broad principles (OR on priority areas and make it a health system initiative, implement simple and holistic ideas, embed OR within routine programme settings, aim for long-term engagement), four related to strategic planning (big team of investigators, joint leadership, decentralised decision-making, working in advance) and three about implementation planning (conducting pilots, smart use of e-tools and operational research publications at frequent intervals). These may act as a guide for other Indian states, high TB burden countries that want to implement differentiated care, and for operational researchers in providing technical assistance for strengthening implementation and conducting OR in health systems and programmes (TB or other health programmes). Following these tips may increase the chances of i) an enriching engagement, ii) policy/practice change, and iii) sustainable implementation.