Development of a target product profile for a point-of-care cardiometabolic device.

INTRODUCTION: Multi-parameter diagnostic devices can simplify cardiometabolic disease diagnosis. However, existing devices may not be suitable for use in low-resource settings, where the burden of non-communicable diseases is high. Here we describe the development of a target product profile (TPP) for a point-of-care multi-parameter device for detection of biomarkers for cardiovascular disease and metabolic disorders, including diabetes, in primary care settings in low- and middle-income countries (LMICs). METHODS: A draft TPP developed by an expert group was reviewed through an online survey and semi-structured expert interviews to identify device characteristics requiring refinement. The draft TPP included 41 characteristics with minimal and optimal requirements; characteristics with an agreement level for either requirement of ≤ 85% in either the survey or among interviewees were further discussed by the expert group and amended as appropriate. RESULTS: Twenty people responded to the online survey and 18 experts participated in the interviews. Twenty-two characteristics had an agreement level of ≤ 85% in either the online survey or interviews. The final TPP defines the device as intended to be used for basic diagnosis and management of cardiometabolic disorders (lipids, glucose, HbA1c, and creatinine) as minimal requirement, and offering an expanded test menu for wider cardiometabolic disease management as optimal requirement. To be suitable, the device should be intended for level 1 healthcare settings or lower, used by minimally trained healthcare workers and allow testing using self-contained cartridges or strips without the need for additional reagents. Throughput should be one sample at a time in a single or multi-analyte cartridge, or optimally enable testing of several samples and analytes in parallel with random access. CONCLUSION: This TPP will inform developers of cardiometabolic multi-parameter devices for LMIC settings, and will support decision makers in the evaluation of existing and future devices.

Cancer in Syrian refugees in Jordan and Lebanon between 2015 and 2017.

Protracted conflicts in the Middle East have led to successive waves of refugees crossing borders. Chronic, non-communicable diseases are now recognised as diseases that need to be addressed in such crises. Cancer, in particular, with its costly, multidisciplinary care, poses considerable financial and ethical challenges for policy makers. In 2014 and with funding from the United Nations High Commissioner for Refugees, we reported on cancer cases among Iraqi refugees in Jordan (2010-12) and Syria (2009-11). In this Policy Review, we provide data on 733 refugees referred to the United Nations High Commissioner for Refugees in Lebanon (2015-17) and Jordan (2016-17), analysed by cancer type, demographic risk factors, treatment coverage status, and cost. Results show the need for increased funding and evidence-based standard operating procedures across countries to ensure that patients have equitable access to care. We recommend a holistic response to humanitarian crises that includes education, screening, treatment, and palliative care for refugees and nationals and prioritises breast cancer and childhood cancers.

Ictal Magnetic Source Imaging in Presurgical Assessment.

Ictal MEG recordings constitute rare data. The objective of this study was to evaluate ictal magnetic source localization (MSI), using two algorithms: linearly constrained minimum variance (LCMV), a beamforming technique and equivalent current dipole (ECD). Ictal MSI was studied in six patients. Three of them were undergoing post-operative re-evaluation. For all patients, results were validated by the stereoelectroencephalographic (SEEG) definition of the epileptogenic zone (EZ). EZ was quantified using the epileptogenicity index (EI) method, which accounts for both the propensity of a brain area to generate rapid discharges and the time for this area to become involved in the seizure. EI values range from 0 (no epileptogenicity) to 1 (maximal epileptogenicity). Levels of concordance between ictal MSI and EZ were determined as follows: A: ictal MSI localized the site whose value EI = 1, B: MSI localized a part of the EZ (not corresponding to the maximal value of EI = 1), C: a region could be identified on ictal MSI but not on SEEG, D: a region could be identified on SEEG but not on MSI, E: different regions were localized on MSI and SEEG. Ictal MEG pattern consisted of rhythmic activities between 10 and 20 Hz for all patients. For LCMV (first maxima), levels of concordance were A (two cases), B (two cases) and E (two cases). For ECD fitted on each time point separately (location characterized by the best goodness-of-fit value), levels of concordance were A (one case), B (one case), D (three cases) and E (one case). For ECD calculated for the whole time window, levels of concordance were A (two cases) and D (four cases). Source localization methods performed on rhythmic patterns can localize the EZ as validated by SEEG. In terms of concordance, LCMV was superior to ECD. In some cases, LCMV allows extraction of several maxima that could reflect ictal dynamics. In a medial temporal lobe epilepsy case, ictal MSI indicated an area of delayed propagation and was non-contributory to the presurgical assessment.

High-performance liquid chromatography with fluorescence detection for the rapid analysis of pheophytins and pyropheophytins in virgin olive oil.

Pheophytins and pyropheophytin are degradation products of chlorophyll pigments, and their ratios can be used as a sensitive indicator of stress during the manufacturing and storage of olive oil. They increase over time depending on the storage condition and if the oil is exposed to heat treatments during the refining process. The traditional analysis method includes solvent- and time-consuming steps of solid-phase extraction followed by analysis by high-performance liquid chromatography with ultraviolet detection. We developed an improved dilute/fluorescence method where multi-step sample preparation was replaced by a simple isopropanol dilution before the high-performance liquid chromatography injection. A quaternary solvent gradient method was used to include a fourth strong solvent wash on a quaternary gradient pump, which avoided the need to premix any solvents and greatly reduced the oil residues on the column from previous analysis. This new method not only reduces analysis cost and time but shows reliability, repeatability, and improved sensitivity, especially important for low-level samples.

Development and validation of a high performance liquid chromatographic method for simultaneous determination of vitamins A and D3 in fluid milk products.

An HPLC method for simultaneous determination of vitamins A and D3 in fluid milk was developed and validated. Saponification and extraction conditions were studied for optimum recovery and simplicity. An RP HPLC system equipped with a C18 column and diode array detector was used for quantitation. The method was subjected to a single-laboratory validation using skim, 2% fat, and whole milk samples at concentrations of 50, 100, and 200% of the recommended fortification levels for vitamins A and D3 for Grade "A" fluid milk. The method quantitation limits for vitamins A and D3 were 0.0072 and 0.0026 µg/mL, respectively. Average recoveries between 94 and 110% and SD values ranging from 2.7 to 6.9% were obtained for both vitamins A and D3. The accuracy of the method was evaluated using a National Institute of Standards and Technology standard reference material (1849a) and proficiency test samples.

Safety, Tolerability, and Pharmacokinetics of an Oral Small Molecule Inhibitor of IL-17A (LY3509754): A Phase I Randomized Placebo-Controlled Study.

For some patients with psoriasis, orally administered small molecule inhibitors of interleukin (IL)-17A may represent a convenient alternative to IL-17A-targeting monoclonal antibodies. This first-in-human study assessed the safety, tolerability, pharmacokinetics (PKs), and peripherally circulating IL-17A target engagement profile of single or multiple oral doses of the small molecule IL-17A inhibitor LY3509754 (NCT04586920). Healthy participants were randomly assigned to receive LY3509754 or placebo in sequential escalating single ascending dose (SAD; dose range 10-2,000 mg) or multiple ascending dose (MAD; dose range 100-1,000 mg daily for 14 days) cohorts. The study enrolled 91 participants (SAD, N = 51 and MAD, N = 40) aged 21-65 years (71% men). LY3509754 had a time to maximum concentration (Tmax) of 1.5-3.5 hours, terminal half-life of 11.4-19.1 hours, and exhibited dose-dependent increases in exposure. LY3509754 had strong target engagement, indicated by elevated plasma IL-17A levels within 12 hours of dosing. Four participants from the 400-mg (n = 1) and 1,000-mg (n = 3) MAD cohorts experienced increased liver transaminases or acute hepatitis (onset ≥ 12 days post-last LY3509754 dose), consistent with drug-induced liver injury (DILI). One case of acute hepatitis was severe, resulted in temporary hospitalization, and was classified as a serious adverse event. No adverse effects on other major organ systems were observed. Liver biopsies from three of the four participants revealed lymphocyte-rich, moderate-to-severe lobular inflammation. We theorize that the DILI relates to an off-target effect rather than IL-17A inhibition. In conclusion, despite strong target engagement and a PK profile that supported once-daily administration, this study showed that oral dosing with LY3509754 was poorly tolerated.

VOC and trace gas measurements and ozone chemistry over the Chesapeake Bay during OWLETS-2, 2018.

The Ozone Water-Land Environmental Transition Study, 2018 (OWLETS-2) measured total non-methane hydrocarbons (TNMHC) and EPA PAMS Volatile Organic Compounds (VOCs) on an island site in the northern Chesapeake Bay 2.1 and 3.4 times greater in concentration, respectively, than simultaneous measurements at a land site just 13 km away across the land-water interface. Many PAMS VOCs had larger concentrations at the island site despite lower NEI emissions over the water, but most of the difference comprised species generally consistent with gasoline vapor or exhaust. Sharp chemical differences were observed between the island and mainland and the immediate air ~300 m above the water surface observed by airplane. Ozone formation potential over land was driven by propene and isoprene but toluene and hexane were dominant over the water with little isoprene observed. VOC concentrations over the water were noted to increase diurnally with an inverse pattern to land resulting in increasing NOx sensitivity over the water. Total reactive nitrogen was lower over the water than the nearby land site, but reservoir compounds (NOz) were greater. Ozone production rates were generally slow (~5 ppb hr-1) both at the surface and aloft over the water, even during periods of high ozone (>70 ppbv) at the water surface. However, specific events showed rapid ozone production >40 ppb hr-1 at the water's surface during situations with high VOCs and sufficient NOx. VOC and photochemistry patterns at the island site were driven by marine sources south of the island, implicating marine traffic, and indicate ozone abatement strategies over land may not be similarly applicable to ozone over the water.Implications: Measured chemical properties and patterns driven primarily by marine traffic sources over water during ozone conducive conditions were starkly different to immediately adjacent land sites, implying ozone abatement strategies over land may not be similarly applicable to ozone over the water.

Strengthening the primary care workforce to deliver high-quality care for non-communicable diseases in refugee settings: lessons learnt from a UNHCR partnership.

Non-communicable disease (NCD) prevention and care in humanitarian contexts has been a long-neglected issue. Healthcare systems in humanitarian settings have focused heavily on communicable diseases and immediate life-saving health needs. NCDs are a significant cause of morbidity and mortality in refugee settings, however, in many situations NCD care is not well integrated into primary healthcare services. Increased risk of poorer outcomes from COVID-19 for people living with NCDs has heightened the urgency of responding to NCDs and shone a spotlight on their relative neglect in these settings. Partnering with the United Nations Refugee Agency (UNHCR) since 2014, Primary Care International has provided clinical guidance and Training of Trainer (ToT) courses on NCDs to 649 health professionals working in primary care in refugee settings in 13 countries. Approximately 2300 healthcare workers (HCW) have been reached through cascade trainings over the last 6 years. Our experience has shown that, despite fragile health services, high staff turnover and competing clinical priorities, it is possible to improve NCD knowledge, skills and practice. ToT programmes are a feasible and practical format to deliver NCD training to mixed groups of HCW (doctors, nurses, technical officers, pharmacy technicians and community health workers). Clinical guidance must be adapted to local settings while co-creating an enabling environment for health workers is essential to deliver accessible, high-quality continuity of care for NCDs. On-going support for non-clinical systems change is equally critical for sustained impact. A shared responsibility for cascade training-and commitment from local health partners-is necessary to raise NCD awareness, influence local and national policy and to meet the UNHCR's objective of facilitating access to integrated prevention and control of NCDs.

Prediction and analysis of functional RNA structures within the integrative genomics viewer.

In recent years, interest in RNA secondary structure has exploded due to its implications in almost all biological functions and its newly appreciated capacity as a therapeutic agent/target. This surge of interest has driven the development and adaptation of many computational and biochemical methods to discover novel, functional structures across the genome/transcriptome. To further enhance efforts to study RNA secondary structure, we have integrated the functional secondary structure prediction tool ScanFold, into IGV. This allows users to directly perform structure predictions and visualize results-in conjunction with probing data and other annotations-in one program. We illustrate the utility of this new tool by mapping the secondary structural landscape of the human MYC precursor mRNA. We leverage the power of vast 'omics' resources by comparing individually predicted structures with published data including: biochemical structure probing, RNA binding proteins, microRNA binding sites, RNA modifications, single nucleotide polymorphisms, and others that allow functional inferences to be made and aid in the discovery of potential drug targets. This new tool offers the RNA community an easy to use tool to find, analyze, and characterize RNA secondary structures in the context of all available data, in order to find those worthy of further analyses.

Effects of conduction delays on the existence and stability of one to one phase locking between two pulse-coupled oscillators.

Gamma oscillations can synchronize with near zero phase lag over multiple cortical regions and between hemispheres, and between two distal sites in hippocampal slices. How synchronization can take place over long distances in a stable manner is considered an open question. The phase resetting curve (PRC) keeps track of how much an input advances or delays the next spike, depending upon where in the cycle it is received. We use PRCs under the assumption of pulsatile coupling to derive existence and stability criteria for 1:1 phase-locking that arises via bidirectional pulse coupling of two limit cycle oscillators with a conduction delay of any duration for any 1:1 firing pattern. The coupling can be strong as long as the effect of one input dissipates before the next input is received. We show the form that the generic synchronous and anti-phase solutions take in a system of two identical, identically pulse-coupled oscillators with identical delays. The stability criterion has a simple form that depends only on the slopes of the PRCs at the phases at which inputs are received and on the number of cycles required to complete the delayed feedback loop. The number of cycles required to complete the delayed feedback loop depends upon both the value of the delay and the firing pattern. We successfully tested the predictions of our methods on networks of model neurons. The criteria can easily be extended to include the effect of an input on the cycle after the one in which it is received.

Borrelia burgdorferi complement regulator-acquiring surface proteins (BbCRASPs): Expression patterns during the mammal-tick infection cycle.

Host complement is widely distributed throughout mammalian body fluids and can be activated immediately as part of the first line of defense against invading pathogens. The agent of Lyme disease, Borrelia burgdorferi sensu lato (s.l.), is naturally resistant to that innate immune defense system of its hosts. One resistance mechanism appears to involve binding fluid-phase regulators of complement to distinct borrelial outer surface molecules known as CRASPs (complement regulator acquiring surface proteins). Using sensitive molecular biology techniques, expression patterns of all three classes of genes encoding the CRASPs of B. burgdorferi sensu stricto (BbCRASPs) have been analyzed throughout the natural tick-mammal infection cycle. Each class shows a different expression profile in vivo and the results are summarized herein. Studies on the expression of B. burgdorferi genes using animal models of infection have advanced our knowledge on the ability of the causative agent to circumvent innate immune defenses, the contributions of CRASPs to spirochete infectivity, and the pathogenesis of Lyme disease.

Lyme borreliosis spirochete Erp proteins, their known host ligands, and potential roles in mammalian infection.

Lyme borreliae naturally maintain numerous distinct DNA elements of the cp32 family, each of which carries a mono- or bicistronic erp locus. The encoded Erp proteins are surface-exposed outer membrane lipoproteins that are produced at high levels during mammalian infection but largely repressed during colonization of vector ticks. Recent studies have revealed that some Erp proteins can serve as bacterial adhesins, binding host proteins such as the complement regulator factor H and the extracellular matrix component laminin. These results suggest that Erp proteins play roles in multiple aspects of mammalian infection.

Production of outer surface protein A by Borrelia burgdorferi during transmission from infected mammals to feeding ticks is insufficient to trigger OspA seroconversion.

The Lyme disease spirochete, Borrelia burgdorferi, produces two outer surface lipoproteins, OspA and OspB, that are essential for colonization of tick vectors. Both proteins are highly expressed during transmission from infected mammals to feeding ticks and during colonization of tick midguts, but are repressed when bacteria are transmitted from ticks to mammals. Humans and other infected mammals generally do not produce antibodies against either protein, although some Lyme disease patients do seroconvert and produce antibodies against OspA for unknown reasons. We hypothesized that, if such patients had been fed upon by additional ticks, bacteria moving from the patients' bodies to the feeding ticks would have produced OspA and OspB proteins, which then led to immune system recognition and antibody production. This hypothesis was tested by analyzing immune responses of infected mice following feedings by additional Ixodes scapularis ticks. However, results of the present studies demonstrate that expression of OspA and OspB by B. burgdorferi during transmission from infected mammals to feeding ticks does not trigger seroconversion.

Utilization of peptide phage display to investigate hotspots on IL-17A and what it means for drug discovery.

To date, IL-17A antibodies remain the only therapeutic approach to correct the abnormal activation of the IL-17A/IL-17R signaling complex. Why is it that despite the remarkable success of IL-17 antibodies, there is no small molecule antagonist of IL-17A in the clinic? Here we offer a unique approach to address this question. In order to understand the interaction of IL-17A with its receptor, we combined peptide discovery using phage display with HDX, crystallography, and functional assays to map and characterize hot regions that contribute to most of the energetics of the IL-17A/IL-17R interaction. These functional maps are proposed to serve as a guide to aid in the development of small molecules that bind to IL-17A and block its interaction with IL-17RA.

The role of neutrophils and monocytic cells in controlling the initiation of Clostridium perfringens gas gangrene.

Clostridium perfringens is a common cause of the fatal disease gas gangrene (myonecrosis). Established gas gangrene is notable for a profound absence of neutrophils and monocytic cells (phagocytes), and it has been suggested that the bactericidal activities of these cells play an insignificant role in controlling the progression of the infection. However, large inocula of bacteria are needed to establish an infection in experimental animals, suggesting phagocytes may play a role in inhibiting the initiation of gangrene. Examination of tissue sections of mice infected with a lethal (1 x 10(9)) or sublethal (1 x 10(6)) inoculum of C. perfringens revealed that phagocyte infiltration in the first 3 h postinfection was inhibited with a lethal dose but not with a sublethal dose, indicating that exclusion of phagocytes begins very early in the infection cycle. Experiments in which mice were depleted of either circulating monocytes or neutrophils before infection with C. perfringens showed that monocytes play a role in inhibiting the onset of gas gangrene at intermediate inocula but, although neutrophils can slow the onset of the infection, they are not protective. These results suggest that treatments designed to increase monocyte infiltration and activate macrophages may lead to increased resistance to the initiation of gas gangrene.

Expected ozone benefits of reducing nitrogen oxide (NOx) emissions from coal-fired electricity generating units in the eastern United States.

On hot summer days in the eastern United States, electricity demand rises, mainly because of increased use of air conditioning. Power plants must provide this additional energy, emitting additional pollutants when meteorological conditions are primed for poor air quality. To evaluate the impact of summertime NOx emissions from coal-fired electricity generating units (EGUs) on surface ozone formation, we performed a series of sensitivity modeling forecast scenarios utilizing EPA 2018 version 6.0 emissions (2011 base year) and CMAQ v5.0.2. Coal-fired EGU NOx emissions were adjusted to match the lowest NOx rates observed during the ozone seasons (April 1-October 31) of 2005-2012 (Scenario A), where ozone decreased by 3-4 ppb in affected areas. When compared to the highest emissions rates during the same time period (Scenario B), ozone increased ∼4-7 ppb. NOx emission rates adjusted to match the observed rates from 2011 (Scenario C) increased ozone by ∼4-5 ppb. Finally in Scenario D, the impact of additional NOx reductions was determined by assuming installation of selective catalytic reduction (SCR) controls on all units lacking postcombustion controls; this decreased ozone by an additional 2-4 ppb relative to Scenario A. Following the announcement of a stricter 8-hour ozone standard, this analysis outlines a strategy that would help bring coastal areas in the mid-Atlantic region closer to attainment, and would also provide profound benefits for upwind states where most of the regional EGU NOx originates, even if additional capital investments are not made (Scenario A). IMPLICATIONS: With the 8-hr maximum ozone National Ambient Air Quality Standard (NAAQS) decreasing from 75 to 70 ppb, modeling results indicate that use of postcombustion controls on coal-fired power plants in 2018 could help keep regions in attainment. By operating already existing nitrogen oxide (NOx) removal devices to their full potential, ozone could be significantly curtailed, achieving ozone reductions by up to 5 ppb in areas around the source of emission and immediately downwind. Ozone improvements are also significant (1-2 ppb) for areas affected by cross-state transport, especially Mid-Atlantic coast regions that had struggled to meet the 75 ppb standard.

Evolving models of Lyme disease spirochete gene regulation.

The spirochete Borrelia burgdorferi, the causative agent of Lyme disease (Lyme borreliosis), is well-adapted to maintain a natural cycle of alternately infecting vertebrates and blood-sucking ticks. During this cycle, B. burgdorferi interacts with a broad spectrum of vertebrate and arthropod tissues, acquires nutrients in diverse environments and evades killing by vertebrate and tick immune systems. The bacterium also senses when situations occur that necessitate transmission between hosts, such as when an infected tick is taking a blood meal from a potential host. To accurately accomplish the requirements necessary for survival in nature, B. burgdorferi must be keenly aware of its surroundings and respond accordingly. In this review, we trace studies performed to elucidate regulatory mechanisms employed by B. burgdorferi to control gene expression, and the development of models or "paradigms" to explain experimental results. Through comparisons of five borrelial gene families, it is readily apparent that each is controlled through a distinct mechanism. Furthermore, those results indicate that current models of interpreting in vitro data cannot accurately predict all aspects of B. burgdorferi environmental sensing and gene regulation in vivo.

Prevalence, care-seeking, and health service utilization for non-communicable diseases among Syrian refugees and host communities in Lebanon.

BACKGROUND: Given the large burden of non-communicable diseases (NCDs) among both Syrian refugees and the host communities within which they are settled, humanitarian actors and the government of Lebanon face immense challenges in addressing health needs. This study assessed health status, unmet needs, and utilization of health services among Syrian refugees and host communities in Lebanon. METHODS: A cross-sectional survey of Syrian refugees and host communities in Lebanon was conducted using a two-stage cluster survey design with probability proportional to size sampling. To obtain information on chronic NCDs, respondents were asked a series of questions about hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and arthritis. Differences in household characteristics by care-seeking for these conditions were examined using chi-square, t-test, and adjusted logistic regression methods. RESULTS: Over half (50.4 %) of refugee and host community households (60.2 %) reported a member with one of the five NCDs. Host community prevalence rates were significantly higher than refugees for all conditions except chronic respiratory diseases (p = 0.08). Care-seeking for NCDs among refugees and host community households was high across all conditions with 82.9 and 97.8 %, respectively, having sought care in Lebanon for their condition. Refugees utilized primary health care centers (PHCC) (57.7 %) most often while host communities sought care most in private clinics (62.4 %). Overall, 69.7 % of refugees and 82.7 % of host community members reported an out-of-pocket consultation payment (p = 0.041) with an average payment of US$15 among refugees and US$42 for the host community (p <0.001). CONCLUSIONS: Given the protracted nature of the Syrian crisis and the burden on the Lebanese health system, implications for both individuals with NCDs and Lebanon's health system are immense. The burden of out of pocket expenses on persons with NCDs are also substantial, especially given the tenuous economic status of many refugees and the less affluent segments of the Lebanese population. Greater investment in the public sector health system could benefit all parties. Efforts to improve quality of care for NCDs at the primary care level are also a critical component of preventing adverse outcomes and lowering the overall cost of care for NCDs.

Direct PCR of Intact Bacteria (Colony PCR).

This protocol describes an efficient method for screening intact bacteria for the presence of desired DNA sequences using the polymerase chain reaction (PCR). This method is commonly referred to as colony PCR. © 2016 by John Wiley & Sons, Inc.