Specific vagus nerve stimulation parameters alter serum cytokine levels in the absence of inflammation.

Background: Electrical stimulation of peripheral nerves is a widely used technique to treat a variety of conditions including chronic pain, motor impairment, headaches, and epilepsy. Nerve stimulation to achieve efficacious symptomatic relief depends on the proper selection of electrical stimulation parameters to recruit the appropriate fibers within a nerve. Recently, electrical stimulation of the vagus nerve has shown promise for controlling inflammation and clinical trials have demonstrated efficacy for the treatment of inflammatory disorders. This application of vagus nerve stimulation activates the inflammatory reflex, reducing levels of inflammatory cytokines during inflammation. Methods: Here, we wanted to test whether altering the parameters of electrical vagus nerve stimulation would change circulating cytokine levels of normal healthy animals in the absence of increased inflammation. To examine this, we systematically tested a set of electrical stimulation parameters and measured serum cytokine levels in healthy mice. Results: Surprisingly, we found that specific combinations of pulse width, pulse amplitude, and frequency produced significant increases of the pro-inflammatory cytokine tumor necrosis factor (TNF), while other parameters selectively lowered serum TNF levels, as compared to sham-stimulated mice. In addition, serum levels of the anti-inflammatory cytokine interleukin-10 (IL-10) were significantly increased by select parameters of electrical stimulation but remained unchanged with others. Conclusions: These results indicate that electrical stimulation parameter selection is critically important for the modulation of cytokines via the cervical vagus nerve and that specific cytokines can be increased by electrical stimulation in the absence of inflammation. As the next generation of bioelectronic therapies and devices are developed to capitalize on the neural regulation of inflammation, the selection of nerve stimulation parameters will be a critically important variable for achieving cytokine-specific changes.

Inhibition of HMGB1/RAGE-mediated endocytosis by HMGB1 antagonist box A, anti-HMGB1 antibodies, and cholinergic agonists suppresses inflammation.

BACKGROUND: Extracellular high mobility group box 1 protein  (HMGB1) serves a central role in inflammation as a transporter protein, which binds other immune-activating molecules that are endocytosed via the receptor for advanced glycation end-products (RAGE). These pro-inflammatory complexes are targeted to the endolysosomal compartment, where HMGB1 permeabilizes the lysosomes. This enables HMGB1-partner molecules to avoid degradation, to leak into the cytosol, and to reach cognate immune-activating sensors. Lipopolysaccharide (LPS) requires this pathway to generate pyroptosis by accessing its key cytosolic receptors, murine caspase 11, or the human caspases 4 and 5. This lytic, pro-inflammatory cell death plays a fundamental pathogenic role in gram-negative sepsis. The aim of the study was to identify molecules inhibiting HMGB1 or HMGB1/LPS cellular internalization. METHODS: Endocytosis was studied in cultured macrophages using Alexa Fluor-labeled HMGB1 or complexes of HMGB1 and Alexa Fluor-labeled LPS in the presence of an anti-HMGB1 monoclonal antibody (mAb), recombinant HMGB1 box A protein, acetylcholine, the nicotinic acetylcholine receptor subtype alpha 7 (α7 nAChR) agonist GTS-21, or a dynamin-specific inhibitor of endocytosis. Images were obtained by fluorescence microscopy and quantified by the ImageJ processing program (NIH). Data were analyzed using student's t test or one-way ANOVA followed by the least significant difference or Tukey's tests. RESULTS: Anti-HMGB1 mAb, recombinant HMGB1 antagonist box A protein, acetylcholine, GTS-21, and the dynamin-specific inhibitor of endocytosis inhibited internalization of HMGB1 or HMGB1-LPS complexes in cultured macrophages. These agents prevented macrophage activation in response to HMGB1 and/or HMGB1-LPS complexes. CONCLUSION: These results demonstrate that therapies based on HMGB1 antagonists and the cholinergic anti-inflammatory pathway share a previously unrecognized molecular mechanism of substantial clinical relevance.

Investigational treatment of rheumatoid arthritis with a vibrotactile device applied to the external ear.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic and debilitating inflammatory disease characterized by extensive joint tissue inflammation. Implantable bioelectronic devices targeting the inflammatory reflex reduce TNF production and inflammation in preclinical models of inflammatory disease, and in patients with RA and Crohn's disease. Here, we assessed the effect of applying a vibrotactile device to the cymba concha of the external ear on inflammatory responses in healthy subjects, as well as its effect on disease activity in RA patients. METHODS: Six healthy subjects received vibrotactile treatment at the cymba concha, and TNF production was analyzed at different time points post-stimulation. In a separate study, nineteen healthy subjects were enrolled in a randomized cross-over study, and effects of vibrotactile treatment at either the cymba concha or gastrocnemius on cytokine levels were assessed. In addition, the clinical efficacy of vibrotactile treatment on disease activity in RA was assessed in nine patients with RA in a prospective interventional study. RESULTS: Vibrotactile treatment at the cymba concha reduced TNF levels, and the suppressive effect persisted up to 24 h. In the cross-over study with 19 healthy subjects, vibrotactile treatment at the cymba concha but not at the gastrocnemius significantly reduced TNF, IL-1ß, and IL-6 levels compared to pre-treatment baseline (TNF p < 0.05, IL-6 p < 0.01, IL-1ß p < 0.001). In healthy subjects, vibrotactile treatment at the cymba concha inhibited TNF by 80%, IL-6 by 73%, and IL-1ß by 50% as compared to pre-treatment baseline levels. In RA patients, a significant decrease in DAS28-CRP scores was observed two days post-vibrotactile stimulation at the cymba concha (DAS28-CRP score pre-treatment = 4.19 ± 0.33 vs post-treatment = 3.12 ± 0.25, p < 0.05). Disease activity remained significantly reduced 7 days following vibrotactile treatment (DAS28-CRP score 7 days post-treatment = 2.79 ± 0.21, p < 0.01). In addition, a persistent improvement in visual analogue scale scores, a patient derived measure of global health assessment, was observed in RA patients following vibrotactile treatment. CONCLUSION: Application of a vibrotactile device to the cymba concha inhibits peripheral blood production of TNF, IL-1ß, and IL-6 in healthy subjects, and attenuates systemic inflammatory responses in RA patients. TRIAL REGISTRATIONS: ClinicalTrials.gov Identifier: NCT01569789 and NCT00859859. The AMC trial conducted in The Netherlands does not have a ClinicalTrials.gov Identifier.

Immunization Elicits Antigen-Specific Antibody Sequestration in Dorsal Root Ganglia Sensory Neurons.

The immune and nervous systems are two major organ systems responsible for host defense and memory. Both systems achieve memory and learning that can be retained, retrieved, and utilized for decades. Here, we report the surprising discovery that peripheral sensory neurons of the dorsal root ganglia (DRGs) of immunized mice contain antigen-specific antibodies. Using a combination of rigorous molecular genetic analyses, transgenic mice, and adoptive transfer experiments, we demonstrate that DRGs do not synthesize these antigen-specific antibodies, but rather sequester primarily IgG1 subtype antibodies. As revealed by RNA-seq and targeted quantitative PCR (qPCR), dorsal root ganglion (DRG) sensory neurons harvested from either naïve or immunized mice lack enzymes (i.e., RAG1, RAG2, AID, or UNG) required for generating antibody diversity and, therefore, cannot make antibodies. Additionally, transgenic mice that express a reporter fluorescent protein under the control of Igγ1 constant region fail to express Ighg1 transcripts in DRG sensory neurons. Furthermore, neural sequestration of antibodies occurs in mice rendered deficient in neuronal Rag2, but antibody sequestration is not observed in DRG sensory neurons isolated from mice that lack mature B cells [e.g., Rag1 knock out (KO) or µMT mice]. Finally, adoptive transfer of Rag1-deficient bone marrow (BM) into wild-type (WT) mice or WT BM into Rag1 KO mice revealed that antibody sequestration was observed in DRG sensory neurons of chimeric mice with WT BM but not with Rag1-deficient BM. Together, these results indicate that DRG sensory neurons sequester and retain antigen-specific antibodies released by antibody-secreting plasma cells. Coupling this work with previous studies implicating DRG sensory neurons in regulating antigen trafficking during immunization raises the interesting possibility that the nervous system collaborates with the immune system to regulate antigen-mediated responses.

Neuronal Circuits Modulate Antigen Flow Through Lymph Nodes.

When pathogens and toxins breech the epithelial barrier, antigens are transported by the lymphatic system to lymph nodes. In previously immunized animals, antigens become trapped in the draining lymph nodes, but the underlying mechanism that controls antigen restriction is poorly understood. Here we describe the role of neurons in sensing and restricting antigen flow in lymph nodes. The antigen keyhole-limpet hemocyanin (KLH) injected into the mouse hind paw flows from the popliteal lymph node to the sciatic lymph node, continuing through the upper lymphatics to reach the systemic circulation. Re-exposure to KLH in previously immunized mice leads to decreased flow from the popliteal to the sciatic lymph node as compared with naïve mice. Administering bupivacaine into the lymph node region restores antigen flow in immunized animals. In contrast, neural activation using magnetic stimulation significantly decreases antigen trafficking in naïve animals as compared with sham controls. Ablating NaV1.8 + sensory neurons significantly reduces antigen restriction in immunized mice. Genetic deletion of FcγRI/FcεRI also reverses the antigen restriction. Colocalization of PGP9.5-expressing neurons, FcγRI receptors and labeled antigen occurs at the antigen challenge site. Together, these studies reveal that neuronal circuits modulate antigen trafficking through a pathway that requires NaV1.8 and FcγR.

The Second World Cholera Pandemic (1826-1849) in the Kingdom of the Two Sicilies with Special Reference to the Towns of San Prisco and Forio d'Ischia.

The second world cholera pandemic in Europe (1829-1849) was significant because of its geographic extent and the enormous numbers of people who fell ill or died. It was also singularly important because it demonstrated the profound levels of ignorance in both Europe and North America concerning the cause, modes of transmission, and treatment of cholera. This paper discusses the pandemic in the Kingdom of the Two Sicilies in great detail. Even though medical and public health authorities in this kingdom had several years to prepare for cholera's eventual arrival in 1836-1837, their elaborate preventive and therapeutic measures proved no more successful than elsewhere. Despite their efforts, it was estimated that there were 32,145 cases of cholera in the city of Naples by July 1837. Some 19,470 people were estimated to have died among the city's then 357,283 population. This amounted to a cholera-specific mortality rate of 54.5/1000 population. Sicily was also severely affected by the epidemic. It was estimated that 69,000 people died of cholera in Sicily, 24,000 of them in the city of Palermo. Two rural towns in the kingdom, San Prisco and Forio d'Ischia, were selected for in-depth epidemiologic study. The former had a population of 3700 in 1836-1837, while the latter had a population of 5500. The economic basis of both towns was agriculture. However, because Forio is located on an island, fishing and sea transport were then also important industries. Cholera appeared in San Prisco in July 1837 and quickly swept through the population. By August, the epidemic was essentially over. It is estimated that some 109 people died from cholera in San Prisco for a disease-specific mortality rate of 29.5/1000 population. The age range of those who died from cholera was 1 to 90 years. The majority of deaths (60.6 %) were among women. The first cases of cholera appeared in Forio d'Ischia in June 1837. The epidemic then peaked in July. It is estimated that approximately 316 people died from cholera in Forio out of a population of 5500. This resulted in a cholera-specific mortality rate of 57.5/1000 population. Among the first 42 fatal cases in whom the disease was documented on their death certificates, ages ranged from 15 to 88 years. The mean age was 52.4 years. The majority of deaths (57.1 %) were among women. We reached beyond the statistics of this epidemic by presenting an in-depth study of the first person to die from cholera in Forio d'Ischia, Nicola Antonio Insante. By focusing on him, we were able to develop a broad account of the social and economic consequences of his death on his family. At the same time, our research demonstrated the resiliency of his immediate and distant descendants. Similarly, we discuss the D'Ambra and Scola families of Forio d'Ischia, and the Caruso and Valenziano families of San Prisco, among whom a number died from cholera in 1837.

Clinical manifestations of Waardenburg syndrome in a male adolescent in Mali, West Africa.

Waardenburg syndrome (WS) is a genetic disorder of which there are four distinct types. These four types are differentiated by the physical defects which they produce. Presented here is the case of a 13-year-old boy with WS Type I who was observed and physically assessed in Mali, West Africa in 1969. His physical findings included a bright blue coloring to the irises of the eyes, profound sensorineural deafness, mutism, dystopia canthorum (lateral displacement of the inner canthi of the eyes), broad nasal root, bushy eyebrows, and scaphoid deformities of the supraorbital portions of the frontal bone. Because family members were not available for interviews or physical examinations, it was not possible to determine if this patient was suffering from a congenital form of the disorder or from a spontaneous mutation. Given the patient's then location in a remote rural area of Mali where electricity was absent, it was not possible to perform additional diagnostic tests. The patient described here is the first with WS in Mali, West Africa to have been medically observed and evaluated and later documented in the medical literature. A second case of the syndrome in Mali was described in the medical literature in 2011 in an 18-month-old infant who did not have sensorineural hearing loss, but who did have a bilateral cleft lip. An historical overview of WS is presented along with details concerning the characteristics of the four types of the disorder.

Smallpox inoculation (variolation) in East Africa with special reference to the practice among the Boran and Gabra of Northern Kenya.

Smallpox inoculation (variolation) was widely reported in sub-Sahara Africa before, during, and after the colonial era. The infective smallpox materials and techniques used, as well as the anatomical sites for inoculation, varied widely among different ethnic groups. The practice among the Boran and Gabra pastoralists of northern Kenya resembled that which was prevalent in a number of areas of Ethiopia. This is not surprising as the Boran also live in southern Ethiopia, and Gabra herdsmen frequently cross the border into this region. The Boran and Gabra technique for smallpox inoculation consisted of taking infective material from the vesicles or pustules of those with active smallpox, and scraping it into the skin on the dorsum of the lower forearm. Although the intent was to cause a local reaction and at most a mild form of smallpox, severe cases of the disease not infrequently resulted. Also, variolated individuals were capable of infecting others with smallpox, thereby augmenting outbreaks and sustaining them. The limited known reports of smallpox inoculation among the Boran and Gabra are presented in this communication. The expansion of vaccination with effective heat stable vaccines, the development of medical and public health infrastructures, and educational programs all contributed to the eventual disappearance of the practice among the Boran and Gabra.

New York City's innovative epidemiologist: the life and career of Morris Greenberg.

Dr Morris Greenberg was an eminent American epidemiologist who served with the New York City Department of Health for a 40 year period, from 1920 until his passing in 1960. In 1946, he became Director of the department's Bureau of Preventable Diseases. In this role, he set very high standards for outbreak and epidemic investigations joined with a commitment to scholarly research and collaboration with the city's medical centers. He received his medical degree from Columbia University College of Physicians and Surgeons and then interned at Bellevue Hospital in New York City. He later trained in pediatrics in Vienna, Austria and received a Master of Science in Public Health degree from Columbia University School of Public Health. In 1942, he became a member of the teaching staff at the School of Public Health. During his years with the New York City Department of Health he led efforts to control outbreaks of smallpox and rickettsialpox, and initiated important studies of poliomyelitis, hepatitis, trichinosis, congenital cardiac anomalies in children, and the embryopathic effects of rubella in pregnancy. Dr. Greenberg's outbreak and epidemic investigations were popularized by The New Yorker writer, Berton Roueché, whose most widely read book remains, Eleven Blue Men and other Narratives of Medical Detection. The book's title is based on Greenberg's investigation of accidental sodium nitrite poisoning among eleven elderly men in Manhattan who as a result, became cyanotic. A pioneer in epidemiology and the prevention and control of communicable disease, Greenberg established very high performance standards for the discipline before there was a Center for Disease Control and Prevention and an Epidemic Intelligence Service in the United States.

Mortality disparities among groups participating in an East Africa surveying expedition: the Herbert Henry Austin expedition of 1900-1901.

In the late nineteenth and early twentieth centuries, a number of European expeditions traveled to the region of Lake Rudolf, now largely in northern Kenya. Although diverse in intent, many of these were undertaken in the interests of furthering colonial territorial claims. In 1900-1901, Major Herbert Henry Austin led a British expedition down to the lake from Khartoum in the north. Of the 62 African, Arab, and European members of this expedition, only 18 (29 %) arrived at its final destination at Lake Baringo in Kenya. Because of a confluence of adverse climatic, social, and political conditions, the expedition ran short of food supplies when it arrived at the northern end of the lake in April 1901. For the next 4 months, the members of the expedition struggled down the west side of the lake and beyond. The greatest mortality (91 %) occurred among the 32 African transport drivers who were the most marginally nourished at the outset of the trip. The lowest mortality among the Africans on the expedition (15 %) occurred among the members of the Tenth Sudanese Rifles Battalion, who had an excellent nutritional status at the start of the expedition. Major Austin himself suffered from severe scurvy with retinal hemorrhages which left him partially blind in his right eye. An analysis of the mortality rates among the groups that participated in this expedition was undertaken. This revealed that poor nutritional status at the start of the trip was predictive of death from starvation.

The management of subacute bacterial endocarditis superimposed on rheumatic heart disease in the immediate pre-penicillin era: the case of Pasquale Imperato.

Subacute bacterial endocarditis (SBE) was invariably a fatal disease in the pre-penicillin era. The availability of sulfonamide antibiotics beginning in the mid-1930s raised hopes that they would be effective in SBE. Unfortunately, except in rare instances, they were not. This paper reviews the clinical experience with sulfonamides in the pre-penicillin period in treating patients with SBE. It presents in detail the case of Pasquale Imperato, who died from the disease at the age of 72 years on 30 November 1942. In so doing, it focuses on the medical management measures then available to treat patients with SBE and on the inevitable course of the illness once it began. Also discussed is the relationship of acute rheumatic fever and its sequela, rheumatic heart disease, to predisposing people to SBE and possible genetic factors. The well-known case of Alfred S. Reinhart, a Harvard Medical School student who died from SBE in 1931 and who kept a detailed chronicle of his disease, is also discussed and contrasted with Pasquale Imperato's case.

Tumor-targeted T cells modified to secrete IL-12 eradicate systemic tumors without need for prior conditioning.

Adoptive cell therapy with tumor-targeted T cells is a promising approach to cancer therapy. Enhanced clinical outcome using this approach requires conditioning regimens with total body irradiation, lymphodepleting chemotherapy, and/or additional cytokine support. However, the need for prior conditioning precludes optimal application of this approach to a significant number of cancer patients intolerant to these regimens. Herein, we present preclinical studies demonstrating that treatment with CD19-specific, chimeric antigen receptor (CAR)-modified T cells that are further modified to constitutively secrete IL-12 are able to safely eradicate established disease in the absence of prior conditioning. We demonstrate in a novel syngeneic tumor model that tumor elimination requires both CD4(+) and CD8(+) T-cell subsets, autocrine IL-12 stimulation, and subsequent IFNγ secretion by the CAR(+) T cells. Importantly, IL-12-secreting, tumor-targeted T cells acquire intrinsic resistance to T regulatory cell-mediated inhibition. Based on these preclinical data, we anticipate that adoptive therapy using CAR-targeted T cells modified to secrete IL-12 will obviate or reduce the need for potentially hazardous conditioning regimens to achieve optimal antitumor responses in cancer patients.

Baylisascaris Procyonis Neural Larva Migrans in an Infant in New York City.

Neural larva migrans (NLM) with eosinophilic meningoencephalitis secondary to raccoon roundworm (Baylisascaris procyonis) infection has been reported in rural and suburban areas of North America and Europe with extant raccoon populations. Most cases have occurred in infants less than two years of age exposed to areas of raccoon fecal contamination. Here, we present a case of Baylisascaris-induced NLM from the densely populated borough of Brooklyn in New York City and alert urban pediatricians to consider this cause of clinical neurologic disease even in areas not typically thought to be associated with endemic risk factors. Infected raccoons also occur in urban settings, and urban children may be exposed to environmental areas or materials contaminated with their feces and the parasite's eggs.

The role of genealogy and clinical family histories in documenting possible inheritance patterns for diabetes mellitus in the pre-insulin era: part 2. Genealogic evidence for type 2 diabetes mellitus in Josephine Imperato's paternal and maternal lineages.

Part 2 presents detailed genealogic information on Josephine Imperato's paternal and maternal lineages extending from four to seven generations into the nineteenth and eighteenth centuries. Among these lineages are some where early adult death over successive generations is perhaps indicative of type 2 diabetes mellitus (type 2 DM). These lineages, all in the town of San Prisco in Italy, include both paternal and maternal ones with the following surnames: Casaccia, Casertano, Cipriano, de Angelis, de Paulis, Peccerillo, Foniciello, di Monaco, Vaccarella, Valenziano, Ventriglia, and Zibella. Genealogic studies of eighteenth and nineteenth century vital records in this area of Italy cannot definitively establish type 2 diabetes mellitus as either an immediate or contributory cause of death. This is because causes of death were not recorded and because disease diagnostic capabilities were largely absent. Genealogic studies of those who lived in Italy in the eighteenth and nineteenth centuries can at best provide data on approximate age at time of death. Early adult death in this era was not uncommon. However, its presence over several successive generations in a lineage raises the possibility of inherited diseases prominent among which is type 2 DM.

The role of genealogy and clinical family histories in documenting possible inheritance patterns for diabetes mellitus in the pre-insulin era: part 1. The clinical case of Josephine Imperato.

Establishing the role of heredity in type 2 diabetes mellitus (type 2 DM) is challenging. While type 2 DM frequently displays a pattern of familial aggregation, many other risk factors are responsible for the clinical expression of the disease. This paper reviews a number of the early twentieth-century studies of inheritance patterns for type 2 DM and presents in detail the history of Josephine Foniciello Imperato (Maria Giuseppa Foniciello) who died from the disease in New York City at the age of 52 years on 14 November 1921, ten months before commercial insulin became available.

The medical exclusion of an immigrant to the United States of America in the early twentieth century. The case of Cristina Imparato.

The medical inspection of immigrants arriving in the United States in the late nineteenth and early twentieth centuries was framed by a need to rapidly process large numbers of people. Scientific medicine, such as it was then, was subordinate to the existing immigration laws which reflected the influences of the powerful anti-immigration forces of eugenics and nativism. The line, or single-file queues in which immigrants were arranged, facilitated rapid processing. The split-second medical gaze was hailed by the then leadership of the U.S. Public Health Service as scientifically sound, based as it was on the alleged exceptional disease detection skills of examining public health physicians. In reality, this system was seriously flawed, led to numerous diagnostic errors, and was free of any form of public outcomes assessment or accountability. In time, trachoma became the principal focus of line physicians because of the belief that it could be easily detected, and those diagnosed with it summarily deported. However, the diagnosis of the early stages of this disease is far more complex since it must be differentiated from other forms of benign conjunctivitis. Described here is the case of Cristina Imparato, a 46-year-old immigrant who arrived in New York from Italy on September 27, 1910, and who was given a diagnosis of trachoma which resulted in her summary deportation three days later on September 30, 1910. Her case serves to illustrate the complex forces at work at that time around the issue of immigration. These included a need to meet the labor needs of expanding industries while responding to the immigration restriction demands of eugenics supporters and nativists and the call to protect the country from imported disease threats.

Beliefs and practices concerning twins, hermaphrodites, and albinos among the Bamana and Maninka of Mali.

The Bamana and Maninka of Mali greatly value twins, and have elaborated a range of cultural beliefs and practices to assure their survival. Rates of twinning among these two ethnic groups average from 15.2/1000 to 17.9/1000 births compared to 10.5/1000 births (without assisted reproduction) in the United States and Great Britain. Twins (flaniw) are regarded as extraordinary beings with unusual powers, and as a gift from the supreme deity. A small altar (sinzin) is maintained in the home of twins, and periodic sacrifices of chicken blood, kola nuts, millet paste and millet beer regularly made to assure their protection. Albinos (yéfeguéw) and true and pseudo-hermaphrodites (tyéténousotéw) are also considered twin beings. However, they are believed to be the result of aberrant parental social behavior. The Bamana and Maninka believe that all four groups (twins, albinos, hermaphrodites, and pseudo-harmaphrodites) are closely linked to Faro, an androgynous supernatural being who provides equilibrium in the world. Faro is the original albino and hermaphrodite who gave birth to the first pair of twins after self-impregnation. Whenever a twin dies, a small wooden statue is sculpted called a flanitokélé (twin that remains). This commemorative figure is kept close to the surviving twin, reflecting a belief in the inseparability of twins. Eventually, the surviving twin takes responsibility for the figure. When a surviving twin marries, another figure is often sculpted in the opposite sex from the deceased twin, and placed with the original sculpture. Such commemorative sculptures are not created upon the death of those who are albinos, hermaphrodites, or pseudo-hermaphrodites. In recent years, transformational belief patterns have evolved as increasing numbers of Bamana and Maninka embrace Islam. Traditional beliefs are often given Islamic myths of origin. However, even in this Islamic context, many practices that assure twin survival are maintained.