The burden of a brain tumor: guiding patient centric care in neuro-oncology.

PURPOSE: Brain tumor patients report an overwhelming sense of uncertainty when navigating the course of their terminal disease. Historically, organizational experts and/or treating physicians have established neuro-oncology programs. However, given the disease burden and incurable nature of current medical treatments, patient-centric care should be prioritized alongside institutional and academic objectives. Integrating patient perspectives into interdisciplinary programmatic development can improve comprehensive care and empower patients to advocate for their own quality healthcare needs. METHODS: Data was derived from four focus groups with adult brain tumor patients (N = 15; Mage = 46 years, 53% female). A trained moderator led each 90-min group and posed semi-structured questions regarding patients' care needs throughout their neuro-oncological disease trajectory. Emphasis was placed on quality of life and psychological distress reduction for both patients and their loved ones. Common themes were identified via thematic content analysis using NVivo software. A high inter-rater reliability (Mkappa = 0.92, range= 0.85-0.93) was achieved. RESULTS: Six distinct themes emerged, where the frequency of each theme ranged from 12.5 to 23.3%. Specifically, patients discussed relational concerns, navigation of interdisciplinary care, neurobehavioral impacts, emotional responses to stressors, existential concerns, and caregiver support. A discussion of themes follows. CONCLUSIONS: It is imperative that we include the patient perspective in the development of neuro-oncology programs; considering the quality of survival in addition to quantity. Neuro-oncology quality care themes identified were relational concerns, navigating interdisciplinary care, neurobehavioral impact, emotional response to stressors, existential concerns, and caregiver support. A paramount concentration for comprehensive neuro-oncology programs must include patients' quality needs.

The Evolving Role of Social Media in Pediatric Orthopaedics.

BACKGROUND: Social media has grown significantly and its application in health care has been dramatically accentuated by the COVID-19 pandemic. It is often considered as a "new dimension" of health care, particularly in its ability to provide health information. In 2017, the top social media sites utilized by pediatric orthopaedic surgeons included Facebook, LinkedIn, and Twitter. In our study, we analyze the current social media usage, trends in Instagram and TikTok content, and the perceptions on social media usage among pediatric orthopaedic surgeons. METHODS: The Pediatric Orthopaedic Society of North America (POSNA) membership directory was searched for the presence of social media. A review of all Instagram and TikTok posts made by the POSNA members were reviewed. A survey regarding the perception of social media networks and content was distributed to all POSNA members. RESULTS: A total of 1231 POSNA members actively practicing in the United States were included in our study. In all, 327 (26.6%) had a LinkedIn profile, 34 (2.8%) had a professional Facebook profile, 15 (1.2%) had a public Instagram account, 0 (0%) had TikTok, and 72 (5.8%) had a professional Twitter account. Fifteen POSNA members with public Instagram accounts had 10,878 followers. A total of 907 Instagram posts were made, 134 (14.8%) of which were education and 462 (50.9%) of which were personal or political. The perception of various social media networks such as Instagram (3.02), Facebook (3.16), and LinkedIn (3.51) were positive on a 5-point Likert scale, while perceptions of TikTok (2.36) and Twitter (2.99) were negative. Educational posts on Instagram (3.19) and Facebook (3.37) were positive. CONCLUSIONS: We provide an update to the utilization of social media by pediatric orthopaedists. Use of Instagram and TikTok accounts remain rare. Educational posts, when hosted on an appropriate social media platform, are perceived positively among pediatric orthopaedists. LEVEL OF EVIDENCE: Level IV.

Changes in microarchitecture of atherosclerotic calcification assessed by 18F-NaF PET and CT after a progressive exercise regimen in hyperlipidemic mice.

BACKGROUND: Despite the association of physical activity with improved cardiovascular outcomes and the association of high coronary artery calcification (CAC) scores with poor prognosis, elite endurance athletes have increased CAC. Yet, they nevertheless have better cardiovascular survival. We hypothesized that exercise may transform vascular calcium deposits to a more stable morphology. METHODS: To test this, hyperlipidemic mice (Apoe-/-) with baseline aortic calcification were separated into 2 groups (n = 9/group) with control mice allowed to move ad-lib while the exercise group underwent a progressive treadmill regimen for 9 weeks. All mice underwent blood collections and in vivo 18F-NaF µPET/µCT imaging both at the start and end of the exercise regimen. At euthanasia, aortic root specimens were obtained for histomorphometry. RESULTS: Results showed that, while aortic calcification progressed similarly in both groups based on µCT, the fold change in 18F-NaF density was significantly less in the exercise group. Histomorphometric analysis of the aortic root calcium deposits showed that the exercised mice had a lower mineral surface area index than the control group. The exercise regimen also raised serum PTH levels twofold. CONCLUSION: These findings suggest that weeks-long progressive exercise alters the microarchitecture of atherosclerotic calcium deposits by reducing mineral surface growth, potentially favoring plaque stability.

Morphological analysis of Francisella novicida epithelial cell infections in the absence of functional FipA.

Francisella novicida is a surrogate pathogen commonly used to study infections by the potential bioterrorism agent, Francisella tularensis. One of the primary sites of Francisella infections is the liver where >90% of infected cells are hepatocytes. It is known that once Francisella enter cells it occupies a membrane-bound compartment, the Francisella-containing vacuole (FCV), from which it rapidly escapes to replicate in the cytosol. Recent work examining the Francisella disulfide bond formation (Dsb) proteins, FipA and FipB, have demonstrated that these proteins are important during the Francisella infection process; however, details as to how the infections are altered in epithelial cells have remained elusive. To identify the stage of the infections where these Dsbs might act during epithelial infections, we exploited a hepatocyte F. novicida infection model that we recently developed. We found that F. novicida ΔfipA-infected hepatocytes contained bacteria clustered within lysosome-associated membrane protein 1-positive FCVs, suggesting that FipA is involved in the escape of F. novicida from its vacuole. Our morphological evidence provides a tangible link as to how Dsb FipA can influence Francisella infections.

A blinded randomized controlled trial to evaluate the use of botulinum toxin for pain control in breast reconstruction with tissue expanders.

BACKGROUND: Tissue expander placement is a common means of reconstruction after mastectomy. Many patients report significant pain and discomfort with the tissue expansion process. Because placement is subpectoral, it was hypothesized that injection of the pectoralis muscle with botulinum toxin could decrease pain associated with tissue expanders. METHODS: A prospective, randomized, double-blinded controlled trial was used to evaluate the effects of intraoperative injection of 100 U of botulinum toxin into the pectoralis muscle on one side versus placebo on the contralateral side during immediate tissue expander reconstruction after bilateral mastectomy. Patients were enrolled in the study between October 2009 and February 2012. Preoperative and postoperative pain scores, number and volume of tissue expansion, and complications were recorded. The paired t test was used to compare preoperative to postoperative changes in pain between the botulinum toxin and placebo injections. RESULTS: Twenty-three patients were enrolled in the trial. There was no statistically significant difference between preoperative to postoperative changes in the pain scores on the botulinum toxin side compared to the control side at any time point postoperatively. All pain scores trended to zero over time. CONCLUSIONS: Intraoperative injection of the pectoralis muscle with botulinum toxin is not an effective method to improve pain control in tissue expander reconstruction.

Intercellular adhesion molecule-1 mediates murine colon adenocarcinoma invasion.

BACKGROUND: Intercellular adhesion molecule-1 (ICAM-1) modulates cell-cell adhesion and is a receptor for cognate ligands on leukocytes. Upregulation of ICAM-1 has been demonstrated in malignant transformation of adenomas and is associated with poor prognosis for many malignancies. ICAM-1 is upregulated on the invasive front of pancreatic metastases and melanomas. These data suggest that the upregulated ICAM-1 expression promotes malignant progression. We hypothesize that the downregulation of ICAM-1 will mitigate tumor progression. METHODS: Mouse colon adenocarcinoma cells (MC38) were evaluated for the expression of ICAM-1 using Western immunoblot analysis. Short hairpin RNA (shRNA) transduction was used to downregulate ICAM-1. Tumor invasion determined via a modified Boyden chamber was used as a surrogate of tumor progression examining MC38 cells, MC38 ICAM-1 knockdowns, and MC38 transduced with vehicle control. The cells were cultured in full media for 24 h and serum-starved for 24 h. A total of 5 × 10(4) cells were plated and allowed to migrate for 24 h using full media with 10% fetal bovine serum as a chemoattractant. Inserts were fixed and stained with crystal violet. Blinded investigators counted the cells using a stereomicroscope. Statistical analysis was performed by analysis of variance with Fischer protected least significant difference and a P value of <0.05 was considered statistically significant. RESULTS: ICAM-1 was constitutively expressed on MC38 cells. Transduction with anti-ICAM-1 shRNA vector downregulated ICAM-1 protein expression by 30% according to the Western blot analysis (P < 0.03) and decreased ICAM-1 messenger RNA expression by 70% according to the reverse transcription-polymerase chain reaction. shRNA knockdown cells had a significant reduction in invasion >45% (P < 0.03). There were no significant differences between the invasion rates of MC38 and MC38 vehicle controls. CONCLUSIONS: Downregulation of ICAM-1 mitigates MC38 invasion. These data suggest that targeted downregulation of tumor ICAM-1 is a potential therapeutic target.

A benefit risk approach in cutoff determination for diagnostic tests.

A crucial step in the design of a diagnostic test is determining the cutoff point, the threshold which separates a negative measurement from a positive one. The results of a diagnostic test have clinical consequences: only when disease is accurately detected, proper treatments be administered, and vice versa. Benefit-Risk (BR) analysis should be used to determine the optimal cutoff point that optimizes the consequence. Quantitative BR analysis requires measurable benefit and risk and a function, e.g., linear or ratio, to combine all the components. When BR corresponding to the four possible diagnostic test outcomes are all scaled in units of risk resulting from an untreated disease, we propose a net BR (linear BR) equation as a function of diagnostic parameters, disease prevalence, benefit of correct diagnosis and risk of false diagnostic results. Optimal cutoff of a diagnostic test can be obtained using this function. Comparison of diagnostic tests based on their benefit and risk of tests is also discussed. Use of this function is illustrated with a biosensor rapid antigen test for SARS-CoV-2.

Hemoglobin-based oxygen carrier mitigates transfusion-mediated pancreas cancer progression.

BACKGROUND: Perioperative blood transfusion in pancreatic cancer patients is linked to decreased survival; however, a causal mechanism has not been determined. Previously we have shown that the plasma fraction of stored packed red blood cells (pRBCs) promotes pancreas cancer progression and associated morbidity. We hypothesize these untoward effects will be mitigated by use of a hemoglobin-based oxygen carrier (HBOC). METHODS: Cytokines and growth factors were measured in the plasma fraction from stored pRBCs and in an HBOC via cytokine array followed by formal enzyme-linked immunosorbent assay (ELISA). In an immunocompetent murine model, pancreas cancer progression was determined in vivo by bioluminescence, tumor weight, and number of metastases. RESULTS: Elevated levels of epidermal growth factor (EGF), platelet-derived growth factor BB (PDGF-BB), and regulated upon activation, normal T cell expressed and secreted (RANTES) were present in the plasma fraction of stored pRBCs, but were not found in the HBOC. Intravenous delivery of plasma fraction to mice with pancreatic cancer resulted in increased bioluminescence activity compared with mice that received HBOC. Metastatic events and pancreatic primary tumor weights were significantly higher in animals receiving plasma fraction from stored pRBCs compared with animals receiving HBOC. CONCLUSIONS: Intravenous receipt of the acellular plasma fraction of stored pRBCs promotes pancreatic cancer progression in an immunocompetent mouse model. These untoward events are mitigated by use of an HBOC.

Revisiting early postinjury mortality: are they bleeding because they are dying or dying because they are bleeding?

BACKGROUND: Intense debate continues in the search of the optimal ratio of blood components to deliver preemptively in the critically injured patient anticipated to require a massive transfusion. A major challenge is distinguishing patients with refractory coagulopathy versus those with overwhelming injuries who will perish irrespective of blood component administration. The hypothesis of this clinical study is that a predominant number of early deaths from hemorrhage are irretrievable despite an aggressive transfusion policy. MATERIALS AND METHODS: During the 7-y period ending in December 2009, there were 772 in-hospital trauma deaths. Each of these deaths had been assigned a cause of death via concurrent review by the multidisciplinary hospital trauma quality improvement committee. Emergency department deaths and patients arriving from outside facilities were excluded from this study. RESULTS: Of the 382 patients (49.5% of total) who died secondary to acute blood loss, 84 (22.0%) survived beyond the ED; of these 84, 68 (81%) were male, mean age was 31 y, and 30 (36%) sustained blunt trauma. Cause of death was determined to be exsanguination in 63 (75%), coagulopathy in 13 (15%), metabolic failure in 5 (6%), and indeterminate in 3 patients (4%). CONCLUSION: These data indicate that 75% of patients who succumb to postinjury acute blood loss are bleeding because they are dying rather than dying because they are bleeding. Conversely, only 13 (2%) of the hospital deaths were attributed to refractory coagulopathy. These critical facts need to be considered in designing studies to determine optimal massive transfusion protocols.

The emotional journey of neuro-oncology: Primary brain tumor patients share their experience during this life-threatening disease.

Background: To achieve patient-centric quality care in neuro-oncology, all aspects of the disease and its impact on quality survival need to be considered. This includes the psychological consequences of a brain tumor diagnosis and subsequent life-altering experiences. Far too often the voice of our patients is unheard. Empowering patients to advocate for their own psychological needs is essential. Methods: Data were derived from four focus groups with adult patients with brain tumors (N = 15; M age = 46 years, 53% female). A trained moderator led each 90-min group and posed semi-structured questions regarding patients' care needs throughout their neuro-oncological disease trajectory. Emphasis was placed on the quality of life and distress reduction. Common themes were identified via thematic content analysis using NVivo software. A high inter-rater reliability (M kappa = 0.92, range = 0.85-0.93) was achieved. Two themes are presented here: Emotional Response to Stressors and Existential Considerations. Results: Of the two themes presented, 14 codes emerged. Codes were classified into three broad categories: Fear, Despair, and Resilience. The frequency of each category ranged from 31.4% to 34.7%. Example quotes and a discussion of each category follows. Conclusions: It is imperative that we include the patient perspective in the development of neuro-oncology programs, thereby considering the quality of survival in addition to quantity. Neuro-oncology quality care must be driven by our patients' experiences and should integrate support for emotional distress while promoting resilience throughout this life-threatening illness.

Amyloid-beta peptide oligomers disrupt axonal transport through an NMDA receptor-dependent mechanism that is mediated by glycogen synthase kinase 3beta in primary cultured hippocampal neurons.

Disruption of axonal transport is a hallmark of several neurodegenerative diseases, including Alzheimer's disease (AD). Even though defective transport is considered an early pathologic event, the mechanisms by which neurodegenerative insults impact transport are poorly understood. We show that soluble oligomers of the amyloid-beta peptide (AbetaOs), increasingly recognized as the proximal neurotoxins in AD pathology, induce disruption of organelle transport in primary hippocampal neurons in culture. Live imaging of fluorescent protein-tagged organelles revealed a marked decrease in axonal trafficking of dense-core vesicles and mitochondria in the presence of 0.5 microm AbetaOs. NMDA receptor (NMDAR) antagonists, including d-AP5, MK-801, and memantine, prevented the disruption of trafficking, thereby identifying signals for AbetaO action at the cell membrane. Significantly, both pharmacological inhibition of glycogen synthase kinase-3beta (GSK-3beta) and transfection of neurons with a kinase-dead form of GSK-3beta prevented the transport defect. Finally, we demonstrate by biochemical and immunocytochemical means that AbetaOs do not affect microtubule stability, indicating that disruption of transport involves a more subtle mechanism than microtubule destabilization, likely the dysregulation of intracellular signaling cascades. Results demonstrate that AbetaOs negatively impact axonal transport by a mechanism that is initiated by NMDARs and mediated by GSK-3beta and establish a new connection between toxic Abeta oligomers and AD pathology.

An emerging occupational rehabilitation system in the People's Republic of China.

INTRODUCTION: China has become a major economic influence in Asia and globally. The country is in the position to further develop its workers' insurance and compensation system. This paper aims to introduce the existing workers' compensation policies, explain how these policies guide the operation of the occupational rehabilitation system for injured workers, and suggest ways to further develop an effective and sustainable system for the country. METHODS: Major government policies and initiative documents and existing literature on occupational rehabilitation were critically reviewed. Shortfalls in our current system were identified and potential further development regimes were propose. RESULTS: Since 2004, China has implemented its national policy on providing timely and comprehensive rehabilitation and return-to-work interventions for workers who are injured at work. The three-tier medical and occupational rehabilitation system appears effective for enabling injured workers to access these services. Such a system is regarded as the most optimal for the country in spearheading the development of quality occupational rehabilitation services, and at the same time incorporating the existing expertise in acute medical care and rehabilitation within the public medical and health system. Problems encountered in the system can be classified under the culture, system and competence building aspects. CONCLUSION: The future workers' insurance and compensation system can probably put more emphasis on using bio-psychosocial and work disability prevention models in guiding its service development and delivery. Efforts need to be placed on building the competence of professionals in the system who provide services for injured workers. The empowerment of important stakeholders in the workers' insurance and compensation system and their inclusion in the planning of service delivery are crucial for developing a sustainable and effective system for China.

FLICE-like inhibitory protein blocks transforming growth factor beta 1-induced caspase activation and apoptosis in prostate epithelial cells.

Androgen withdrawal induces the regression of human prostate cancers, but such cancers eventually become androgen-independent and metastasize. Thus, deciphering the mechanism of androgen withdrawal-induced apoptosis is critical to designing new therapies for prostate cancer. Previously, we showed that in the rat, castration-induced apoptosis is accompanied by a reduction in the expression of the apical caspase inhibitor FLICE-like inhibitory protein (FLIP). To test the functional role of FLIP in inhibiting prostate epithelial cell apoptosis, we employed the rat prostate epithelial cell line NRP-152, which differentiates to a secretory phenotype in a low-mitogen medium and then undergoes apoptosis following the addition of transforming growth factor beta1 (TGFbeta1), mimicking androgen withdrawal-induced apoptosis. FLIP levels decline with TGFbeta1 treatment, suggesting that apoptosis is mediated by caspase-8 and indeed the caspase inhibitor crmA blocks TGFbeta1-induced apoptosis. Small interfering RNA-mediated knockdown of FLIP recapitulates and enhances TGFbeta1-induced cell death. NRP-152 cells stably transfected with constitutively expressed FLIP were refractory to TGFbeta1-induced apoptosis. TGFbeta1-induced caspase-3 activity is proportional to the level of cell death and inversely proportional to the level of FLIP expression in various clones. Moreover, neither caspase-3 nor PARP is cleaved in clones expressing high levels of FLIP. Furthermore, insulin, which inhibits differentiation, increases FLIP and inhibits TGFbeta-induced death in a FLIP-dependent manner. Although neither Fas-Fc, sTNFRII-Fc, nor DR5-Fc blocked TGFbeta1-induced cell death, there is a significant increase in tumor necrosis factor mRNA following TGFbeta stimulation, suggesting both an unexpected role for tumor necrosis factor in this model system and the possibility that FLIP blocks another unknown caspase-dependent mediator of apoptosis.

Prediction model for the return to work of workers with injuries in Hong Kong.

This study attempts to formulate a prediction model of return to work for a group of workers who have been suffering from chronic pain and physical injury while also being out of work in Hong Kong. The study used Case-based Reasoning (CBR) method, and compared the result with the statistical method of logistic regression model. The database of the algorithm of CBR was composed of 67 cases who were also used in the logistic regression model. The testing cases were 32 participants who had a similar background and characteristics to those in the database. The methods of setting constraints and Euclidean distance metric were used in CBR to search the closest cases to the trial case based on the matrix. The usefulness of the algorithm was tested on 32 new participants, and the accuracy of predicting return to work outcomes was 62.5%, which was no better than the 71.2% accuracy derived from the logistic regression model. The results of the study would enable us to have a better understanding of the CBR applied in the field of occupational rehabilitation by comparing with the conventional regression analysis. The findings would also shed light on the development of relevant interventions for the return-to-work process of these workers.

International employee perspectives on disability management.

PURPOSE: To provide an international analysis of employees' views of the influence of disability management (DM) on the workplace. METHODOLOGY: An international research team with representation from Australia, Canada, China, and Switzerland collected survey data from employees in public and private companies in their respective regions. Due to lack of availability of current measures, a research team-created survey was used and a total of 1201 respondents were collected across the four countries. ANALYSIS: Multiple linear (enter) regression was also employed to predict DM's influence on job satisfaction, physical health, mental health, workplace morale and reduced sickness absence, from respondents' perceptions of whether their company provided disability prevention, stay-at-work, and return-to-work initiatives within their organization. One-way ANOVA comparisons were used to examine differences on demographic variables including company status (public versus private), union status (union versus nonunion), and gender. RESULTS: The perceived influence of DM programs was related to perceptions of job satisfaction; whereas, relationships with mental health, physical health, morale, and sickness absence were variable according to type of DM program and whether the response was related to self or others. Difference analyses (ANOVA) revealed significantly more positive perceptions for private and nonunion organizations; no gender effects were found. CONCLUSIONS: There is perceived value of DM from the perspective of employees, especially with respect to its value for coworkers. Implications for Rehabilitation Rehabilitation efforts should continue to focus attention on the value of disability management (DM). In particular, DM that is fully committed to the biopsychosocial model would be supported by this research. Employees reported the most value in the psychosocial variables addressed by DM, such that rehabilitation professionals could focus on these valued aspects to improve buy-in from employees. The interest in coworker value may provide another avenue for rehabilitation efforts to increase uptake, by highlighting the value of intervention efforts for employee coworkers. Rehabilitation professionals in union environments may need to be particularly cognizant of the need for encouraging psychosocial and coworker value potentially seen by employees in order to increase acceptance and participation for organizational DM efforts.

Healthy aging for caregivers: what are their needs?

The aim of this study was to design a culture-sensitive scale to measure caregiver's burden for the purpose of identifying their needs in Taiwan. In this study, four factors were identified as caregiver's top priority needs: "personal factors," "relation factors," "financial factors," and "reward factors." Definitions for each factor are also discussed. The total variances explained by the four factors are 34%, 13%, 9%, and 8%, respectively. The results show caregivers in Taiwan place more emphasis on their physical and emotional interaction with the care-receivers than is found in other cultures. Policy recommendations inferred from these findings are made. It is necessary for the government or organizations to provide services to fulfill caregivers' needs to promote a healthy aging process of the caregivers themselves. Participants who cared for their elderly parents or relatives were selected randomly from the island of Taiwan. The total selected sample size of caregivers is 2524, who were caring for 3504 persons. Data were analyzed by univariate, bivariate, and multivariate methods. Maximum Likelihood Extraction Factors Analysis and LISREL for Structural Equation Modeling methods were used to confirm and make final the structure of the scale. Recommendations and suggestions are provided for further studies on culturally sensitive projects.

Structure of the conserved Francisella virulence protein FvfA.

Francisella tularensis is a potent human pathogen that invades and survives in macrophage and epithelial cells. Two identical proteins, FTT_0924 from F. tularensis subsp. tularensis and FTL_1286 from F. tularensis subsp. holarctica LVS, have previously been identified as playing a role in protection of the bacteria from osmotic shock and its survival in macrophages. FTT_0924 has been shown to localize to the inner membrane, with its C-terminus exposed to the periplasm. Here, crystal structures of the F. novicida homologue FTN_0802, which we call FvfA, in two crystal forms are reported at 1.8 Šresolution. FvfA differs from FTT_0924 and FTL_1286 by a single amino acid. FvfA has a DUF1471 fold that closely resembles the Escherichia coli outer membrane lipoprotein RscF, a component of a phosphorelay pathway involved in protecting bacteria from outer membrane perturbation. The structural and functional similarities and differences between these proteins and their implications for F. tularensis pathogenesis are discussed.

Strategies for teaching loss, grief, and bereavement.

Teaching loss, grief, and bereavement to nursing students should be an interactive process to stimulate critical thinking and address the affective domain of learning. Lecture as a teaching methodology may be the easiest to prepare and deliver; however, used alone, it is ineffective in identifying perceptions, fears, and issues related to dying and death. Personal and professional experiences of loss, grief, and bereavement are central to student's learning of effective and compassionate care of the dying patient and their family. Strategies that explore such experiences allow students to move forward and focus on the cognitive retention of content related to loss, grief, and bereavement, as well as the ability to learn related psychomotor skills. The authors discuss pedagogical methods for teaching student nurses about loss, grief, and bereavement utilizing the End of Life Nursing Education Consortium (ELNEC) curriculum training materials.

Examination of in vitro epithelial cell lines as models for Francisella tularensis non-phagocytic infections.

Francisella tularensis (F. tularensis), the causative agent of tularemia, has long been known to invade and occupy non-phagocytic epithelial cells. Many epithelial cell infection models have been developed to study this process; however, due to the lack of consensus on infection methods and precise experimental procedures to evaluate invasion and replication, selection of appropriate models to use based on the literature is challenging. To evaluate in vitro non-phagocytic cell infection models, we chose 8 epithelial cultured cell lines from published models to infect with F. tularensis subspecies novicida (F. novicida) and compared the results to a recently developed model that used the mouse hepatocyte BNL CL.2 cell line. We utilized classical gentamicin-based invasion assays to determine total intracellular bacterial loads and employed microscopic examination with staining techniques that distinguished between intracellular and extracellular bacteria to provide an accurate assessment of the proportion of invaded host cells and the degree of bacterial replication. We found that COS-7 cells exhibited the greatest invasion rates; CMT-93 cells contained the largest intracellular bacterial loads; ad HEK-293s were capable of invasion and replication rates at high levels, but required shorter infection incubation times. Although COS-7, CMT-93 and HEK-293 cell lines may be suited to study certain aspects of invasion or replication, we found that BNL CL.2 cells appeared the most appropriate to study the overall pathogenesis of F. novicida when examined in toto.