There is increasing interest in using social media sites such as Facebook to deliver health interventions so as to expose people to content while they are engaging in their usual social media habit. This formative intervention development study is novel in describing a preliminary test of using the secret group feature of Facebook to deliver a behavioral intervention targeting users of indoor tanning beds to reduce their risk of skin cancer. Intervention content was designed to challenge body image-related constructs associated with indoor tanning through the use of dissonance-inducing content.To evaluate engagement with and acceptability of using a secret Facebook group to deliver a healthy body image intervention to young women engaged in indoor tanning.Seventeen young women completed a baseline survey and joined a secret Facebook group with intervention content delivered via daily posts for 4 weeks. Engagement data was extracted and acceptability was measured via a follow-up survey.P=.08, Cohen d=0.47).The study had a high retention rate . On average, posts were viewed by 91% of participants, liked by 35%, and commented on by 26%. The average comment rate was highest (65%) for posts that elicited comments by directly posing questions or discussion topics to the group. Average intervention acceptability ratings were highly positive and participants reported feeling connected to the group and its topic. Average rates of past 1-month indoor tanning reported following the intervention were lower than the baseline rate  may vary based on post types and that designing specifically labeled discussion posts may be helpful for soliciting engagement as well as challenging beliefs. Social media allows for the unlimited exchange of information, images, and interactive peer communication. Researchers have begun to utilize Facebook, the most popular social media site -3, to deThe intervention approach is guided by body image theories that demonstrate cultural experiences can negatively impact how young women view their bodies and may lead to a preoccupation with obtaining an unrealistic, culturally-derived ideal appearance ,8. The nThe purpose of this proof-of-concept study was to test engagement with and acceptability of delivering a dissonance-based, body image focused intervention to reduce indoor tanning using Facebook secret groups. For this intervention, content was posted daily on the group page for four weeks and group members were encouraged to share and discuss their opinions about the posts. We also examined the preliminary efficacy of the intervention by comparing rates of participants’ tanning bed use before and after the intervention.Participants were 18 to 25-year-old women who used Facebook at least once a day and a tanning bed at least once in the past year. Recruitment utilized multiple methods including: emailing study invitations to participants from our prior focus group study on tanners’ intervention preferences; distributing recruitment flyers to students on a large northeastern US college campus; posting study flyers on social media accounts ; and ads on local Craigslist pages. Research staff conducted study screening phone calls with interested participants to evaluate study eligibility. A total of 17 participants were enrolled .Study procedures included a baseline survey, participation in a four-week Facebook group, and a post-intervention survey 5 weeks after baseline. The study was conducted from July to August 2016. Enrolled participants were emailed a link and a unique PIN to complete the online baseline survey. Participants received a US $30 gift card for each survey and those who completed both were entered in a US $100 gift card raffle. The university’s Institutional Review Board approved all study procedures and participants provided online consent.The intervention consisted of a secret invitation-only Facebook group named “RU Facebook Project”. The group feature of Facebook is designed to connect and share information with a subset of Facebook users based on shared interests. With Facebook secret groups, Facebook users receive a private invitation to join a group, which in this study was used to post the intervention messages. Further, secret group membership and content is limited to invited group members and their group membership and in-group activities are not publicly viewable to outside Facebook users. A study Facebook account was created and used to deliver all intervention content via daily group posts. Two authors, JS and AD, joined the group with study-specific Facebook user accounts to provide a “face” for the researchers and increase study credibility. Our involvement was purposefully limited to include: encouraging initial comments and responses to discussion questions by JS and AD—commenting once each on the first “icebreaker” post and AD commenting once on each of the next two discussion posts—and liking comments from participants throughout the study to reinforce participation.Your Thoughts posts, the primary approach for encouraging dissonance processing, were adapted from group-based discussion questions from prior disordered eating interventions. Content for inspirational posts were primarily procured from popular media sources including Facebook. Most posts (93%) were written to generally focus on body image and women’s experiences rather than specifically addressing indoor tanning in order to reduce possible reactance to content from tanners while still addressing an important predictor of tanning behavior. There was no predetermined order of presentation of post types and we varied their order across the 4-week intervention period to avoid making repetitive post types across multiple days. Your Thoughts discussion posts were made every 2-3 days and the homework posts were made in weeks 3 and 4 as they were designed to have group members apply knowledge learned earlier in the intervention period.The goals of the dissonance-based Facebook intervention approach mirrored those of existing interventions for disordered eating and indoor tanning ,15-17 inIntervention receipt was defined as the percent of posts viewed by participants. Engagement was assessed as interactions with group posts . Engagement results are presented both as “post engagement”, defined as the mean number of likes and comments received by post types, and “participant engagement”, defined as the number of likes and comments averaged across participants. Facebook data was manually extracted from the group newsfeed after the posting period ended.not at all and 10= extremely) ) with the remaining having a bachelor's degree or higher (18% [3/17]). Eleven out of seventeen (65%) participants used Facebook multiple times a day and 5 out of 17 (29%) reported daily use at baseline.All enrolled participants completed the baseline assessment and accepted our invitation to join the Facebook group. Sixteen out of seventeen participants completed the post-intervention survey, producing a 94% study retention rate.Twelve out of seventeen participants (70.6%) viewed every post and an additional four (23.5%) viewed at least 75% of posts. An average of 91.4% participants viewed each post See  and the Participants provided favorable ratings on general intervention evaluation items including: interesting (mean 7.5 [SD 1.7]); understandable (mean 9.1 [SD 1.3]); useful (mean 8.2 [SD 1.7]); and positive . Means for Facebook-specific evaluation items indicated a general level of agreement with regard to perceived connectedness to the group  includin15=1.90, P=.08: Cohen d=0.47).The mean number of reported past 1 month indoor tanning sessions was lower at the post-intervention assessment (mean 0.7 [SD 2.3]) compared to baseline (mean 2.3 [SD 4.4]) although this difference was not significant at the α=.05 level (tYour Thoughts) received higher rates of comments than other post types. The labeling of posts as discussion posts may be helpful for soliciting engagement as well as challenging beliefs. For participant-level engagement, mean number of likes was slightly higher than comments. Overall, the observed rates of intervention engagement compare favorably to Facebook interventions on other topics  ) viewed every post, and an additional 23.5% [4/17] viewed at least 75% of posts. Post engagement, measured by likes and comments, differed according to post type. Posts specifically designed to elicit comments by posting questions and discussion topics to the group  -28.Ratings on general measures of intervention acceptability  were favorable and comparable to other tanning interventions delivered via booklet or website ,20. FaceThis formative study has some notable limitations. First, the study had a single arm design, small sample size, and was not fully powered to detect behavior change or examine psychosocial intervention mediators. Second, the sample was primarily recruited from a single geographic area using specific inclusion criteria that reduce generalizability of the findings. Our discussion posts were adapted from in-person, group-based disordered eating interventions that utilize discussion questions designed specifically to generate counter-attitudinal responses to challenge image ideals  (eg, “DeIn conclusion, social media represents an unexplored platform for delivering dissonance-based interventions for disordered eating and indoor tanning. The current formative study demonstrates the feasibility and acceptability of using Facebook as a delivery mechanism for these types of interventions. The use of Facebook groups to deliver dissonance-based interventions capitalizes on features key to the success of these interventions including group-based discussions and peer support. Embedding the intervention into the target population’s social media routine facilitates both engagement and reaches with less expense than in-person groups and developing websites incurs. The utilization of Facebook groups for delivering group-based interventions is appealing given the potential for creating highly sustainable intervention approaches with strong potential for dissemination across multiple geographic locations.


Glioblastoma multiforme (GBM) is a highly aggressive form of brain cancer with marginal survival rates. GBM extracellular acidosis can profoundly impact its cell fate heterogeneities and progression. However, the molecules and mechanisms that enable GBM tumor cells acid adaptation and consequent cell fate competencies are weakly understood. Since extracellular proton concentrations (pHe) directly intercept the tumor cell plasma membrane, surface lipids must play a crucial role in pHe-dependent tumor cell fate dynamics. Hence, a more detailed insight into the finely tuned pH-dependent modulation of surface lipids is required to generate strategies that can inhibit or surpass tumor cell acid adaptation, thereby forcing the eradication of heterogeneous oncogenic niches, without affecting the normal cells.physiological: pHe 7.4, low: 6.2, and very low: 3.4) on LN229 glioblastoma cell line surface remodeling and analyzed the consequent cell fate heterogeneities with relevant molecular targets and behavioral assays. Through this basic study, we uncovered that the extracellular proton concentration (1) modulates surface cholesterol-driven cell fate dynamics and (2) induces ‘differential clustering’ of surface resident GM3 glycosphingolipid which together coordinates the proliferation, migration, survival, and death reprogramming via distinct effects on the tumor cell biomechanical homeostasis. A novel synergy of anti-GM3 antibody and cyclophilin A inhibitor was found to mimic the very low pHe-mediated GM3 supraclustered conformation that elevated the surface rigidity and mechano-remodeled the tumor cell into a differentiated phenotype which eventually succumbed to the anoikis type of cell death, thereby eradicating the tumorigenic niches.By using image-based single cell analysis and physicochemical techniques, we made a small-scale survey of the effects of pH ranges (via the crucial interplay of surface lipids and their conformational changes. Hence, monitoring of proton–cholesterol–GM3 correlations in vivo through diagnostic imaging and in vitro in clinical samples may assist better tumor staging and prognosis. The emerged insights have further led to the translation of a ‘pH-dependent mechanisms of oncogenesis control’ into the surface targeted anti-GBM therapeutics.This work presents an initial insight into the physicochemical capacities of extracellular protons in the generation of glioblastoma tumor cell heterogeneities and cell death  Extracellular tumor acidification (pHe) is a well-recognized hallmark of cancer progression –6.Consolidated information from several studies has brought forth the knowledge that tumor masses can demonstrate heterogeneous pHe levels ranging from 7.4 to 6.2 units, in general, that can fall as low as 5.5–3.4 units and even below –9. This http://glioblastoma.alleninstitute.org/, follow ‘documentation tab’ and ‘overview’ under document sub-section). Figure The glioblastomas are characterized by four main tumor zones with distinct cellular phenotypes that are histopathologically discernable (In acidic extracellular microenvironment (pHe), differential proton concentrations directly intercept the tumor cell surface. In the case of physiologically pH-adapted cells, such as those lining the kidney and gastric lumen, a high surface residency of cholesterol and GM3 glycosphingolipid is observed Figure –13, whicHence in this study, we have specifically addressed: (1) how extracellular protons can work to generate differential glioblastoma/tumor cell fates, that is, what cell fates competence is associated with which extracellular pH ranges and (2) whether extracellular proton concentrations differentially modify cholesterol and GM3 biophysical and molecular properties that can crucially impact the intratumoral cell fate heterogeneities?in vitro observations with GBM pathology, we examined the GBM patient data, as distinct histopathological zones of GBMs are presumptively associated with certain pH microenvironments  the biophysical–biochemical capacities of protons, (ii) the differential cell fates they generate, and (iii) how surface cholesterol and GM3 participate in this process. To further explore the corroboration of our in vitro . Later, acidosis , 19.R’ denotes the colocalization coefficient between wheat germ agglutinin (binds to cell surface marker) and LAMP2 surface localization]. Hence, to some extent, extrapolation of acidosis-driven in vitro observations with comparable evidences in different tumor zones of GBM patient samples may be relevant in this study and may present fresh insights into the development of the therapeutic strategies/diagnostic biomarkers from the results obtained.We too found that LAMP2 surface localization was significantly enhanced in the regions attributed with ‘very low’ (necrotic zone) and ‘low pH’  in the glioblastoma patient samples Figure B  moieties at pH 6.2 and 3.4, followed by intermolecular interaction via galactose   bonds [Figure The results obtained by us in bi-component membrane simulations at pH 7.4 are much in concert with the recent report on MSD data of GM3 clusters on complex lipid membranes . HoweverTo further understand the basis of competence of different pHs in evolving GM3 receptor heterogeneity by local spatial changes in its glycan headgroups, we studied the tilt angles Figure C.We further investigated the compression of lipids per unit area in response to the decreasing pH. Results show that ‘area per lipid’ was reduced at low and very low pHs, suggesting an evolution of high lipid packing density. Hence, enhanced lipid packing at low pH and very low pH indicated the probability of high compressional stress on the membrane Figure D.vs. grade II . GM3 was highly enriched in the necrotic and luminal zones where it showed large punctate/clustered patterns on the cellular surface (phenotypes designated by numbers 6 and 3)  at physiological and low pH had reduced size and number of clusters, in comparison to the high cholesterol pH conditions, but pH 6.2 (−veCD) showed more number of clusters than pH 7.4 (−veCD), which was also predicted by our simulation data. Both GM3 cluster size and cluster fluorescence intensity that essentially denoted the number of expressing pixels in a cluster were found to be highly correlated in each condition Figure B.2) that were organized in a polarized pattern. However, the pH 6.2 exposed cells had comparatively fewer punctate clusters in the range of 0.17 μm2 but rather showed some larger sized clusters (0.34 μm2 and above), probably due to the high levels of cholesterol in these conditions. The few but larger clusters observed in pH 6.2 +veCD condition could have exerted a high compressional force on the tumor cells, forcing a spherical mitotic geometry, which might be the reason for the observed highest proliferative index of this condition  at physiological pH 7.4 showed numerous small sized GM3 clusters  treated cells, suggesting that the major micron-sized GM3 clustering was cytoskeleton dependent. Since +veCD conditions also showed enhanced clustering, it can be assumed that micron-sized clusters were cholesterol and cytoskeleton dependent.We confirmed that the clustering patterns obtained were not due to the cluster detection assay performed at a low temperature because in experiments where the cells that were first fixed at the room temperature and then probed for surface GM3 also showed similar surface patterns as seen when the GM3 antibody was incubated on the surface of live cells that were kept on ice, to prevent antibody endocytosis Figure  did not vs. GM3–GM3 glycan ligated clusters in our pH conditions. Data showed that GM3 lactonization was rather minimal as the digestion of the sialic acid by sialidases, dramatically reduced surface GM3 detection at all pHs, which would not have been the case if detected clusters were predominantly lactones, as GM3 lactones are resistant to such enzymatic treatment  as almost 100% anoikis was observed in 50–60 h post-treatment.We find that in blebbed conditions Figure , GM3 cluvia the GM3 antibody-mediated clustering at both physiological and low pHs. The loss of protumorigenic receptors and signaling lattices through extensive surface blebbing could be one of the possible causes for this differentiation-like state.The cytoskeleton too was similarly disrupted as observed in the acid stress experiments Figure . HoweverR values). The clusters in the non-necrotic zones were small and spread throughout the cells or were small and polarized. Hence, these results show that not just GM3 but GM3 supraclustered conformations must be associated with the tumor cell death.Indeed, necrotic and peri-necrotic zones (associated with low pH environments) in glioblastoma patient samples showed extensive GM3 and GFAP colocalization and supraclustering Figure , which wInhibition of cyclophilin binding to its surface receptors by cyclosporin A has been evidenced to impact GFAP expression . CyclophWe observed that a potent cyclophilin A inhibitor  at a verTo enhance the supraclustering effects, we incubated the anti-GM3 antibody and cyclophilin A inhibitor together and found far prominent cell surface blebbing accompanied by an extensive rupture of the cytoskeleton Figure . In thisvia cross-linking served as an effective therapeutics to eradicate not only low pH zones but also the tumor cells that were growing in physiological pH microenvironments. This combination treatment hence converged the tumor cell heterogeneity into anoikis zones . We further find that other GBM cell lines, U87MG and U373, when treated in a like manner, showed similar anoikis phenotype while normal cells such as epidermal keratinocytes (HaCaT), mouse astrocytes, and neurons were unaffected Figures A–C. Hencs Figure D.in vivo system clearance of the dead cells.The major goals of this study were (1) to identify how glioblastoma tumor cells respond to changes in the extracellular pH ranges leading to the heterogeneous cell fates; (2) how very low pHe causes growth arrest and (3) whether such identified growth arrest mechanisms can be simulated in the oncogenic pH environments, hijacking their biophysical homeostasis and molecular response machineries, to further transform them into the non-oncogenic phenotype (4) and force them to die by anoikis (a de-adhesion induced cell death), which could be further followed by secondary necrosis that permits better The above mentioned queries were answered by two major findings that generated crucial insights into the role of surface lipids as targets in acidosis and in anticancer therapeutics.first finding indicated that pHe ranges exhibit differential capacities to modulate glioblastoma cell fate dynamics in a cholesterol-sensitive manner. Data showed that (1) lowering of pHe raised surface cholesterol probably as an adaption to prevent acid hydrolysis of the plasma membrane. A concomitant rise in proliferation index was observed for low pH conditions. (2) Tumor cells at physiological pH, when chemically manipulated to raise surface cholesterol, also showed enhanced proliferation. (3) High cholesterol containing tumor cells in pH microenvironment of 6.2 units showed highest proliferation competencies. Hence, high cholesterol seemed to increase the proliferation potential.The via anoikis-a ‘loss of anchorage’ mediated cell death. Interestingly, when the protective umbrella of enhanced surface cholesterol was removed from the low and very low pH microenvironments, the tumor cells underwent rapid anoikis, while physiological pH-adapted cells were unharmed. These results suggest that surface cholesterol plays a crucial role in tumor cell adaptation to acidosis and can be developed into a prognostic and diagnostic marker.On the contrary, basal cholesterol tumor cells at pH 7.4 showed maximum migration competence and anchorage-independent growth (which is associated with the emergence of more stem-like properties). Biophysical and molecular characterizations suggested that rise in cholesterol may have led to surface rigidity which supports proliferation but de-promotes stem-like characteristics , 71. Versecond main finding took leads from the first and describes how extracellular pH levels–cholesterol cross talk impacts the GM3 glycosphingolipid surface clustering, wherein very high proton concentration-driven and cholesterol-sensitive GM3–GM3 ligations were capable of generating strong substrate de-adhesion forces, levitating the tumor cells and hence driving tumor cell fate to anoikis type of cell death. The work further describes how insights from proton concentration-driven GM3 supraclustering mechanisms inspired us to take an alternative approach to generate GM3 supraclusters via synergistic application of anti-GM3 antibody to first potentiate the oncogenic tumor cell niches into differentiation and then into subsequent cell death, hence presenting novel insights into tumor therapeutics.The via GM3 supraclustering effects   , 9. Henchttp://meetinglibrary.asco.org/print/2387331, also see via photodynamically inducing proton release from tumor cells. However, the mechanism by which extracellular protons can manipulate tumor cell surface and downstream cell fate needed elucidation. Hence, our work also mechanistically complements the above report. Our observations further caution that very high concentration of protons will be required for direct acid-driven therapies; otherwise, it may lead to further promotion of oncogenesis  of Rajiv Gandhi Centre for Biotechnology (RGCB).RM designed the research; SJ and RM performed the research and wrote the manuscript. RM and KS performed molecular simulations. All authors have read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer CG and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


Cortical circuit reorganization induced by anodal transcranial direct current stimulation (tDCS) over the Broca’s area of the dominant language hemisphere in 13 healthy adults was quantified by functional near-infrared spectroscopy (fNIRS). Transient cortical reorganization patterns in steady-state functional connectivity  and temporal functional connectivity  were recorded before, during, and after applying high current tDCS . fNIRS connectivity mapping showed that tDCS induced significantly ( Meinzer et al.One additional aspect of tDCS studies that remains underexplored to date is the effect of electrode placement on language performance. For example, Monti et al.,This work is a first step toward addressing the aformentioned knowledge gaps in tDCS studies, namely (1) to study the effect of stimulation current on the steady-state and temporal connectivity changes in brain networks related to language processing and (2) to study whether lower current tDCS patterns could produce changes in connectivity patterns that are qualitatively similar to those observed during and after the application of larger tDCS currents. Here, we have studied the effect of tDCS current intensity on the cortical connectivity maps of healthy adults by use of functional near-infrared spectroscopy (fNIRS). fNIRS can detect changes in the concentration of oxyhemoglobin (HbO) and deoxyhemoglobin (Hb) resulting from neurovascular couplingSeveral fNIRS-tDCS studies have been reported in the past years. Merzagora et al.22.1Thirteen right-hand subjects  connected by a pair of saline-soaked gauze covered gel electrodes  analysis2.5.3Graph theory analysis was applied to investigate the changes in topographical patterns of functional networks across the entire cortical regions mapped by fNIRS. In our study, for each subject, we defined each fNIRS channel as a node, resulting in a total of 83 nodes. The edges ,,A certain range of [Clustering coefficient Characteristic path length The global efficiency ,,Small-world properties  higondition . HoweverIn addition, 3.2,In addition, paired 3.3As described in Sec. ,Furthermore, no significant differences were found in the AUC of 4,This study systematically explored by use of resting state fNIRS the impact of two different anodal tDCS exposures applied over the left Broca’s area, on functional connectivity reorganization. A lower tDCS current (low current tDCS) was applied to create transient hemodynamic changes, whereas a higher current (high current tDCS) mimicked a current dose that is typical of tDCS interventions reported in the literatures.4.1,,–,,,Seed-based analysis revealed distinct differences in functional connectivity patterns between low current tDCS, high current tDCS, and within 10 min after high current tDCS. Specifically, low current tDCS was more likely to suppress the connections with long distance brain regions, while high current tDCS encouraged increased local connectivity. Interestingly, during the after high current tDCS session, a return to the suppression of long-distance connections was seen, combined with the short-distance increased connectivity seen during the immediately preceding high current tDCS session. It is hypothesized that anodal tDCS-induced subthreshold neuronal depolarization, which reduced the amount of excitatory input required, resulting in the excitation of the stimulated cortical areas near the anodal electrode.4.2,,,In contrast to steady-state functional connectivity that focuses on connectivity strength, FCV focuses on the variation of the connectivity strength of transient states. It was observed  that all4.3,,In contrast with seed-based functional connectivity, graph theory analysis quantified network connectivity changes induced by tDCS across the entire cortical area mapped by fNIRS. tDCS induced an increase in the density of local connections between detector channels across the entire cortical network that was quantified by the network’s small-world features. These network features were the characteristic path length . We conducted the same analyses when excluding the two female subjects and the vast majority of results did not change, with three exceptions. First, when comparing the no tDCS versus low current tDCS conditions, there was one more channel located in the contralateral BA21 and one channel located in the ipsilateral BA8 with significantly decreased functional connectivity with the seed on left Broca’s area and right Broca’s homologue, respectively (5Our work demonstrates the feasibility of using resting-state fNIRS to study cortical network reorganization induced by tDCS in the language processing cortical networks of healthy subjects. Seed-based functional connectivity, graph theory analysis, and time-variant functional connectivity were used to track changes in cortical functional connectivity for these networks. Seed-based connectivity and graph theory analyses revealed increased local and decreased remote functional connectivity induced by tDCS. At the same time, time-variant functional connectivity changes suggested that tDCS increased FCV of remote connections. In addition, low current tDCS produced qualitatively similar patterns of increases in clustering coefficient and FCV, but did not produce patterns of increased local connectivity observed during and immediately after high current tDCS. The qualitative similarity of connectivity patterns seen between the low current tDCS and after high current tDCS conditions hints at the possibility of using multiple electrode placements with low stimulation currents in a single protocol to gain insight into what these changes could be at higher currents for each subject. Nevertheless, the validity of this approach needs to be tested in further work involving stimulation during performance of a task so that connectivity changes could be associated with observable task performance changes.


Recent studies have identified links between host genetic variants and microbial recognition of the microbiome. Defects in host–microbiome interactions in individuals harboring inflammatory bowel disease risk alleles may result in imbalances of the microbial community, impaired pathogen clearance, and failure to sense beneficial commensal microbes. These findings highlight the importance of maintaining bi-directional communication at the mucosal interface during intestinal homeostasis. Inflammatory bowel disease (IBD), encompassing Crohn’s disease (CD) and ulcerative colitis (UC), is an idiopathic, chronic intestinal inflammatory disease involving complex interactions between genetic and environmental factors. There is significant variability in symptoms and clinical manifestations, which may partly reflect the genetic heterogeneity of IBD susceptibility. Indeed, close to 200 IBD susceptibility genes have been identified thus far, though the lack of complete penetrance indicates that additional unknown factors are likely to be involved in pathogenesis . Among tThe interplay between the gut epithelium and the microbiota has also been implicated as a contributing factor in disease pathogenesis, whereby aberrant interactions may result in inflammatory responses to commensal microbes . It has NOD2), a cytosolic innate immune pattern recognition receptor and the first CD susceptibility gene identified, has been reported to play key roles in maintaining intestinal homeostasis through its detection of peptidoglycan from the microbiota. A large body of evidence has revealed a role for NOD2 in shaping the composition of the gut microbiota in IBD patients as well as in animal models [Nod2−/− mice, specifically with an expansion of Bacteroides vulgatus, a pathobiont [CARD9), another CD susceptibility gene whose product interacts with NOD2, was recently found to impact the gut microbiota, whereby Card9−/− mice harbor a more pro-inflammatory population of microbes with impaired tryptophan metabolism [Card9−/− mice into wild-type germ-free mice resulted in increased susceptibility to colitis, delayed recovery from disease, and reduced IL-22 responses compared to wild-type controls [Lactobacillus strains was sufficient to rescue susceptibility to colitis. These and other findings clearly show that innate immune sensors and response regulators, such as NOD2 and CARD9, respectively, limit the expansion of disease-promoting microorganisms in the gut, allowing beneficial microbes to thrive, and thus contribute to host health.The relationship between host genetics and the composition of the gut microbiota has been explored extensively , 5. The l models , with a thobiont . The genNOD2 are believed to be impaired in bacterial recognition and clearance, resulting in sustained intestinal inflammation—a notion supported by studies of Nod2−/− mice in response to bacterial infections [ATG16L1 (autophagy-related 16 like 1) and IRGM (immunity-related GTPase M), along with NOD2, being associated with CD susceptibility [Atg16l1, Irgm, or Nod2 have all been reported to be impaired in pathogen clearance. Moreover, defects in ATG16L1 result in diminished secretion of antimicrobial peptides from abnormal Paneth cells and reduced antigen presentation—all features that may contribute to IBD pathogenesis [The close interaction between the host and the microbiota involves the shaping of the microbiota by the host and concurrent signaling from commensal microbes through immune-mediated recognition receptors to promote host tissue and immune development . Maintaifections . Furtherfections , 7. GWASAtg16l1 or Nod2 were unable to induce regulatory T-cell responses to suppress mucosal inflammation upon treatment with Bacteroides fragilis, both in vitro and during experimental colitis [ATG16L1 risk allele T300A were unable to respond to B. fragilis in vitro compared to immune cells carrying the protective T300 allele, indicating that a functional ATG16L1 protein is required for the induction of anti-inflammatory responses by immunomodulatory bacterial molecules. Therefore, in addition to their role in bacterial clearance, we have proposed a complementary role for ATG16L1 and NOD2, in which these immune pathways also participate in the sensing of beneficial microbes [In addition to the detection and clearance of intracellular pathogens, we recently revealed a role for ATG16L1 and NOD2 in sensing immunomodulatory commensal bacteria to promote tolerogenic immune responses to maintain intestinal homeostasis. Mouse dendritic cells deficient in either  colitis . Furthermicrobes . Our worWhile host genetics and the gut microbiome have separately been considered to be contributing factors to host health and disease in various immune-mediated pathologies, it is now clear that the synergism between these two players is key to our understanding of the pathogenesis of IBD. The intestinal microbial community has evolved alongside the host, contributing to immunity and energy metabolism . EmerginExploring gene–gut microbiome interactions may uncover novel strategies for early diagnosis and treatment of IBD. As probiotics and fecal microbiota transplant therapies become increasingly prevalent for IBD treatment, there is also a need to understand the mechanisms by which host immune pathways integrate microbiome-derived signals to promote intestinal homeostasis. Understanding whether individuals carrying risk alleles associated with IBD are receptive to the beneficial effects of microbial therapies will facilitate personalized approaches to treatment. The implications of the microbiome on precision medicine may be an important consideration for treatment of IBD and other immune-mediated diseases. In fact, recent studies have shown that the gut microbiome can predict patient responsiveness to immunomodulatory therapies, including both chemotherapies and an anti-integrin therapy (vedolizumab) used in IBD . A perso


TIA1 mutations, together with comparisons to sporadic ALS (sALS) and ALS due to repeat expansions in C9orf72 (C9orf72+). All nine patients with confirmed mutations in TIA1 were female. The clinical phenotype was heterogeneous with a range in the age at onset from late twenties to the eighth decade (mean = 60 years) and disease duration from one to 6 years (mean = 3 years). Initial presentation was either focal weakness or language impairment. All affected individuals received a final diagnosis of ALS with or without FTD. No psychosis or parkinsonism was described. Neuropathological examination on five patients found typical features of ALS and frontotemporal lobar degeneration  with anatomically widespread TDP-43 proteinopathy. In contrast to C9orf72+ cases, caudate atrophy and hippocampal sclerosis were not prominent. Detailed evaluation of the pyramidal motor system found a similar degree of neurodegeneration and TDP-43 pathology as in sALS and C9orf72+ cases; however, cases with TIA1 mutations had increased numbers of lower motor neurons containing round eosinophilic and Lewy body-like inclusions on HE stain and round compact cytoplasmic inclusions with TDP-43 immunohistochemistry. Immunohistochemistry and immunofluorescence failed to demonstrate any labeling of inclusions with antibodies against TIA1. In summary, our TIA1 mutation carriers developed ALS with or without FTD, with a wide range in age at onset, but without other neurological or psychiatric features. The neuropathology was characterized by widespread TDP-43 pathology, but a more restricted pattern of neurodegeneration than C9orf72+ cases. Increased numbers of round eosinophilic and Lewy-body like inclusions in lower motor neurons may be a distinctive feature of ALS caused by TIA1 mutations.Mutations in the stress granule protein T-cell restricted intracellular antigen 1 (TIA1) were recently shown to cause amyotrophic lateral sclerosis (ALS) with or without frontotemporal dementia (FTD). Here, we provide detailed clinical and neuropathological descriptions of nine cases with  TIA1) as a cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) . He. He19]. Over the subsequent 4 years, her extremity weakness progressed to the point of requiring full assistance for daily activities. She became increasingly dysarthric and had difficulty breathing, but was able to swallow. A change in personality was first noted 6 months before her death when she became disinhibited, mildly disoriented, inappropriately emotional and repetitive. She died at age 55 with a clinical diagnosis of ALS and early behavioral variant FTD (bvFTD). An autopsy limited to brain and spinal cord was performed. Neuropathological examination showed ALS-TDP and FTLD-TDP (subtype B) and tau-ir neurofibrillary tangles restricted to the entorhinal and transentorhinal cortex (Braak stage I).The sister of the proband was assessed at age 55. Neither she nor her family reported any motor or cognitive symptoms. Clinical neurological assessment was normal; however, detailed neuropsychological assessment found deficits on measures of verbal and non-verbal memory. She was considered symptomatic , but not demented.The niece of the proband developed difficulty with word-finding at age 28. Around the same time, her family noted that she was becoming emotionally flat, withdrawn, apathetic and displaying little empathy. A few months later she developed dysarthria, difficulty chewing and swallowing and she became clumsy and prone to minor injury. Language comprehension began to decline, she was increasingly forgetful and had difficulty planning and organizing simple household tasks. She had suffered from dyslexia since childhood, as had several of her paternal relatives. When initially evaluated, 6–9 months following her disease onset, her Mini-Mental Status Examination (MMSE) score was 21/30, the Montreal Cognitive Assessment test (MoCA) showed prominent visuospatial dysfunction and the Frontal Assessment Battery (FAB) was 3/15. There was mild emotional incontinence. She had a slight spastic dysphonia and mild Gegenhalten in the right arm and leg. MRI demonstrated moderate symmetric frontotemporal atrophy.When next evaluated, at age 29, she was found to have more severe cognitive impairment (MMSE score of 11/30 and MoCA score of 8/30). She was friendly but apathetic and emotionally blunt. Her speech was anomic, dysarthric and perseverative, but grammatically intact. She could follow simple commands and repeat sentences. Although her aphasia was difficult to classify, it was felt to have features of apraxia of speech and progressive non-fluent aphasia (PNFA). Physical examination was limited by her inability to fully cooperate. Strength of her facial muscles was normal, but tongue movement was impaired. Jaw jerk was brisk and she was hyperreflexic and mildly spastic in all extremities. Muscle bulk and strength were normal in all extremities and no fasciculations were noted. EMG showed active denervation, fibrillation potentials, irritability and some positive sharp waves in several muscles of both legs; however, due to patient noncompliance, the EMG study was discontinued before the upper extremities could be tested. The clinical diagnosis was that of primary progressive aphasia  and “probable” ALS (due to the incomplete EMG study).She progressed rapidly and became almost mute with a very limited degree of language comprehension within the next 6 months. Her bulbar dysfunction worsened and the right lower extremity became weak. She died at age 30 with a clinical diagnosis of FTD with both behavioral symptoms and progressive aphasia and probable ALS. Autopsy limited to brain and spinal cord demonstrated ALS-TDP and FTLD-TDP (subtype B).This woman presented at age 65 with intermittent confusion and aphasia characterized by laconic speech, word finding difficulties and paraphasic errors in writing, but with intact language comprehension. No motor features were identified at that time and she was given a preliminary clinical diagnosis of primary progressive aphasia (PPA).More detailed evaluation at age 67 found apraxia of speech, dysarthria, telegraphic phrases, anomia, problems with sentence comprehension and agrammatic writing. There were also impairments in executive function, motivation and insight. Motor examination demonstrated bulbar weakness, but normal limb strength and reflexes without fasciculations. MRI showed extensive cerebral white matter hyperintensities, attributed to chronic ischemia, and SPECT scan showed mild hypoperfusion of the left anterior temporal lobe.Her disease progressed rapidly and by age 68 she had global aphasia, swallowing difficulties and fasciculations in the tongue and all limbs. EMG revealed findings of motor neuropathy and spontaneous motor activity, and swallowing studies were abnormal. She died later that year. Her family history was positive for late onset dementia, but not for ALS.An autopsy was performed but was limited to the brain. Neuropathological examination showed FTLD-TDP (type B) and ALS-TDP pathology in the brainstem and high cervical spinal cord. There was very mild Alzheimer-type pathology with rare neuritic senile plaques and neurofibrillary tangles (Braak stage II).This woman presented at age 73 with speech abnormalities characterized by frequent errors in grammar and syntax. Her speech progressively deteriorated and she also developed swallowing difficulties with frequent choking. Neuroimaging studies were unremarkable and she was diagnosed with PNFA and probable ALS. She developed depressive symptoms, but no other behavioral abnormalities. Her family history was negative for neurological disorders. Neuropathological examination showed ALS-TDP and FTLD-TDP (type B).This 75-year old woman presented with approximately 7 months of bulbar weakness and pseudobulbar affect and was diagnosed with clinically definite ALS. Her ALS Functional Rating Scale (ALSFRS) score was 25/48 and the ALS Cognitive Behavioral Screen (ALS-CBS) was compatible with probable frontotemporal cognitive impairment with expressive aphasia. She died at age 76. There was no family history of ALS, dementia or Parkinson disease. Post-mortem examination was not performed.This woman presented at age 63 with progressive bulbar weakness. By age 64 she met clinical criteria for definite ALS and required ventilatory support. Her ALSFRS score was 29/48. ALS-CBS was normal and she did not have any cognitive or behavioral symptoms. She was subsequently lost to follow up. Family history was positive for ALS and Parkinson disease.This woman presented at age 58 with 4 months of bulbar symptoms and was diagnosed with clinically definite ALS. Her ALSFRS score was 43/48 and ALS-CBS scores were normal. She died 21 months after disease onset. There was no family history of ALS, dementia or Parkinson disease. Autopsy limited to brain and spinal cord showed ALS-TDP and mild TDP-43 pathology in the extramotor cerebral cortex.This woman presented at age 64 with sudden onset of bilateral leg weakness and back pain. EMG performed 4 months later showed widespread denervation in the legs and thoracic paraspinal muscles; however, weakness was only demonstrated in the distal legs. Over the following year, her weakness became more severe and spread to involve proximal legs, arms and face with a hyperactive jaw jerk and increased tone in the legs. Her respiratory function declined to a forced vital capacity of 33%. Cognitive testing performed at age 65 was normal with MMSE 30/30 and ALSCBS 19/20. She died at age 66. There was no history of neurological disorders in the family. Post-mortem examination was not performed.The fresh brain weight ranged from 1132 to 1450 g (mean 1300 g) with two cases showing bifrontal lobar atrophy (UBCU2-1 and UBCU2-14) and one with left side predominant frontotemporal atrophy (TOR-1). The hippocampi were normal in size and only one case showed mild atrophy of the head of the caudate nucleus. Mild or moderate reduction in the pigmentation of the substantia nigra was noted in four cases.The pyramidal motor system showed chronic degenerative changes in all cases Table . The priThe four cases with clinical features of FTD also showed degeneration of the extramotor neocortex, with the prefrontal regions being most consistently and severely affected Table , Fig. 2fTDP-ir pathology tended to be more severe and anatomically widespread than the degenerative changes Table . There wMany of the remaining LMN in the spinal cord and hypoglossal nucleus contained TDP-ir NCI of varying morphology Fig. . Most coTDP-ir glial inclusions were not quantified separately but were a common feature in affected grey matter regions as well as the subcortical white matter. They were relatively uncommon in the corticospinal tracts and rare in other spinal cord funiculi.Most cases did not show any other significant neurodegenerative pathology. Mild Alzheimer-type pathology was present in two cases with tau-ir neurofibrillary tangles limited to the entorhinal and transentorhinal cortex  and infrequent neuritic senile plaques . No alpha-synuclein-ir Lewy bodies or neurites were present.TIA1 mutations, C9orf72 mutations and sALS without either mutation . This difference was all the more striking given that the analysis included the TIA1 mutation case with only a single section of high cervical spinal cord available for examination (NWU-1). Although that case had only one round inclusion and no LBLI in the single cervical section  than C9orf72+ or sALS cases  was used  in combination with each of the three TIA1 antibodies that gave the best results with IHC. The same types of NCI were labelled for pTDP-43 as had been seen on light microscopy with TDP-43 IHC .IHC using a number of anti-TIA1 primary antibodies that recognize different TIA1 epitopes Table  failed tIHC Fig. . The TIAIHC Fig. . IHC usiTIA1 mutations that cause ALS ± FTD. Although the number of cases currently available is not extensive, it is sufficient to identify some features that may be helpful in distinguishing these cases from other ALS subtypes.The purpose of this report is to provide a detailed description of the clinical and neuropathological features associated with the recently identified TIA1 mutations were identified in 2.2% of familial ALS and 0.4% of sporadic ALS cases [C9orf72 repeat expansion , but simutation . Only thutations  and suggof 1.7:1  and coulTIA1 mutation carriers varied, with five presenting with symptoms of ALS, three with early changes of FTD and one who was asymptomatic but found to have abnormal memory function of neuropsychological testing (Table C9orf72 mutation (44%) [TIA1 mutation carriers is different from those with the C9orf72 mutation whose FTD phenotype is more often bvFTD [TIA1 mutations in patients with mainly FTD. Interestingly, none of our TIA1 mutation carriers developed significant parkinsonism or psychotic features, both of which are commonly reported in series with the C9orf72 mutation [The initial clinical features of our on (44%) . Of the en bvFTD . It is imutation , 27.TIA1 (E384K) was previously identified in Swedish and Finnish populations to cause WDM, which is characterized by late-onset slowly progressive weakness of hand and distal leg muscles and is associated with a rimmed vacuolar myopathy which is TDP-ir [TIA1 mutations had a personal or family history of muscle disease. It is possible that something about the specific amino acid substitution caused by the E384K mutation leads to a distinct and selective phenotype, or that the expression is influenced by other genetic factors common to the specific ethnic population in which the WDM TIA1 mutation occurs [TIA1 mutations in biophysical and cell culture studies [VCP, SQSTM1, HNRNPA1, HNRNPA2B1 and MATR3), in which mutations cause clinical syndromes, referred to as multisystem proteinopathies, with ALS, FTD, inclusion body myopathy and bone disease each showing variable penetrance [It is intriguing that another founder mutation affecting the LCD of s TDP-ir , 15. To  studies , it is anetrance .TIA1 mutations was characterized by chronic degenerative changes, primarily involving the pyramidal motor system, prefrontal neocortex and substantia nigra, with more anatomically widespread TDP-ir pathology  [Overall, the neuropathology of our patients with gy Table  and 3. Imutation . None oftations) , 20.TIA1 mutation carriers was the number of round, sometimes LBL inclusions seen in LMN of the spinal cord and medulla with HE stain (Fig. C9orf72+ cases, they never averaged more than one per tissue section and were completely absent in most cases. In contrast, round and LBL inclusions were a consistent feature in the TIA1 mutation carriers, with at least one, and often multiple examples, present in each section of spinal cord and medulla. Consistent with this was the finding of significantly more compact round TDP-ir NCI in LMN in the TIA1 mutation cases, which were often of a similar size and shape as the round/LBL inclusions seen on HE stain. This finding suggests that frequent round/LBLI in LMN may represent a pathological signature of ALS-TDP caused by TIA1 mutations and that the formation of these particular inclusion bodies may somehow be related to the altered SG dynamics that has been shown to be associated with expression of the mutant TIA1 protein [SOD1 mutations [The most striking aspect of the pyramidal system pathology in the ain Fig. . Althoug protein . Althougutations , 23, wheutations .TIA1 mutations is that the amino acid change in the LCD enhances its intermolecular interaction, which promotes LLPS and results in SG that are more persistent, thus creating an environment where the contents are more likely to begin to aggregate and become insoluble [TIA1 mutations. Although some other studies have suggested that TIA1 may co-localize with TDP-43 in ALS [TIA1 mutation carriers [The pathomechanism that has been proposed for ALS associated with nsoluble . Althoug3 in ALS , 32, othcarriers . This suTIA1. The clinical presentation is distinguished by frequent bulbar onset weakness and a predominance of expressive aphasia, and by the absence of associated parkinsonian or psychotic features. Although the disease appears to be inherited in an autosomal dominant fashion, the lack of family history in many cases suggests that penetrance may be variable. The striking predominance of females in our series needs to be confirmed, but suggests that expression of the mutation may be influenced by some sex-related factor. The anatomical pattern of neurodegeneration correlates with the main clinical features and these cases tend not to show the caudate atrophy or hippocampal sclerosis that is common with the C9orf72 mutation. The molecular neuropathology is a combination of FTLD-TDP type B and ALS with TDP-ir inclusions. However, the most striking pathological feature is the consistent presence of round, often LBL inclusions that are visible on HE stain and correlate with an increased frequency of compact TDP-ir NCI in LMN. There is currently no evidence for any abnormal distribution or accumulation of TIA1 protein in postmortem brain tissue of TIA1 mutation carriers; however, this warrants more detailed investigation. Additional studies are clearly needed to confirm and expand upon this initial characterization. In particular, the presence of TIA1 mutations needs to be investigated in patients with clinically pure FTD and families with TIA1 mutations should be reviewed for evidence of multisystemic features such as muscle and bone disease. Even though this initial case series is relatively small, the detailed clinical and pathological characterization will be helpful in identifying additional cases that might carry a TIA1 mutation and provides a baseline upon which future studies can build.In summary, this analysis of a small series of cases provides an initial characterization of the clinical and pathological features in patients with ALS ± FTD caused by mutations in


For nearly four decades, the N400 has been an important brainwave marker of semantic processing. It can be recorded non-invasively from the scalp using electrical and/or magnetic sensors, but largely within the restricted domain of research laboratories specialized to run specific N400 experiments. However, there is increasing evidence of significant clinical utility for the N400 in neurological evaluation, particularly at the individual level. To enable clinical applications, we recently reported a rapid evaluation framework known as “brain vital signs” that successfully incorporated the N400 response as one of the core components for cognitive function evaluation. The current study characterized the rapidly evoked N400 response to demonstrate that it shares consistent features with traditional N400 responses acquired in research laboratory settings—thereby enabling its translation into brain vital signs applications.Data were collected from 17 healthy individuals using magnetoencephalography (MEG) and electroencephalography (EEG), with analysis of sensor-level effects as well as evaluation of brain sources. Individual-level N400 responses were classified using machine learning to determine the percentage of participants in whom the response was successfully detected.The N400 response was observed in both M/EEG modalities showing significant differences to incongruent versus congruent condition in the expected time range (p < 0.05). Also as expected, N400-related brain activity was observed in the temporal and inferior frontal cortical regions, with typical left-hemispheric asymmetry. Classification robustly confirmed the N400 effect at the individual level with high accuracy (89%), sensitivity (0.88) and specificity (0.90).The brain vital sign N400 characteristics were highly consistent with features of the previously reported N400 responses acquired using traditional laboratory-based experiments. These results provide important evidence supporting clinical translation of the rapidly acquired N400 response as a potential tool for assessments of higher cognitive functions. ERPs ar) ending . It was In the 38 years since its initial report, the N400 response has been studied extensively using a variety of stimulus paradigms in various healthy and clinical populations –14. WhilThe cortical generators of the N400 response have been investigated using numerous noninvasive imaging modalities, such as functional magnetic resonance imaging (fMRI), electroencephalography (EEG), as well as magnetoencephalography (MEG). Results have revealed widespread cortical activations across the left temporal lobe, along with smaller areas of activity in the right temporal as well as bilateral inferior frontal and parietal regions , 21–23. spectrum of brain responses which provide a more complete profile of brain function [Further to its functional relevance as an indicator of neural processing in healthy individuals, the N400 response has also shown significant potential as a diagnostic and prognostic tool in clinical populations , 26–33. function . This isfunction . Under tTo assess the N400 response within a short testing time while providing information about other brain function indicators, our group has been undertaking systematic development of rapid evaluation techniques in recent years. We previously demonstrated the successful evaluation of the N400 response in 100 healthy individuals using a point-of-care enabled device , then emAlthough the rapid evaluation brain vital sign framework showed initial promise as a potential avenue for clinical application of the N400 ERP, the component characteristics of this rapidly elicited N400 (rN400) response have not yet been described. Given the short, complex stimulus paradigm, it is crucial to characterize this response with respect to its spatiotemporal, spectral, and neuroanatomical features, and compare them with known N400 characteristics reported in studies using more conventional approaches over the last few decades.The current study utilized MEG with simultaneous EEG to investigate the temporal, spatial, spectral, and neuroanatomical characteristics of the rN400 response elicited within the brain vital sign framework. We hypothesized that the rN400 response will exhibit features consistent with known characteristics of the N400 response, including: (1) increased ERP negativity and MEG signal power for the incongruent relative to congruent condition during the 300–500 ms post-stimulus interval; (2) decreased beta- band power for the incongruent relative to congruent condition during the same interval; and (3) increased activation of temporal and frontal cortices  for processing of incongruent relative to congruent stimuli.Seventeen (17) right-handed healthy participants with no history of neurological problems or psychoactive medication were recruited . Participants were undergraduate or graduate students, had normal hearing, normal or corrected-to-normal vision, and were fluent in English. The study was approved by ethics boards at Fraser Health Authority and Simon Fraser University, and all participants provided written informed consent.congruent condition, 50%, e.g. doctor-nurse) were contrasted with words not semantically linked  to generate the differential processing measures. Words in both groups were balanced for characteristics such as word frequency and length, and the words in the semantically linked group had a minimum Cloze probability of 0.8 [As introduced elsewhere , the rapy of 0.8 . The stiA 151-channel CTF MEG  was used with concurrent 3-channel EEG, both recorded in a magnetically shielded room with the participants in the supine position. Data were sampled at 1200 Hz using axial gradiometers (5-cm baseline) with synthetic 3rd order gradients employed for noise cancellation. Continuous head position monitoring was undertaken by three head position indicator coils located at fiducial points . EEG recordings utilized Ag/AgCl scalp electrodes placed at Fz, Cz and Pz locations, with impedances kept below 5 kOhms. Four additional electrodes were placed on the head corresponding to reference (left mastoid), ground (forehead), horizontal (outer canthus of left eye) and vertical  electro-occulogram (EOG). To facilitate the alignment of MEG scanner and head coordinate systems, the shape of the participants’ head and the 3-dimensional position of HPI coils and EEG/EOG electrodes were recorded using a Polhemus electromagnetic digitization system prior to data collection . Auditory stimulation was presented binaurally using insert earphones, and participants were instructed to maintain visual fixation on a crosshair displayed on the overhead screen (white cross on black background) throughout the session.Raw data for both MEG and EEG were first visually inspected, and artifactual channels removed from further analysis. Data were then down-sampled to 300 Hz, notch filtered to remove frequencies corresponding to power line (60 Hz) with its harmonics as well as HPI coils, and low-pass filtered to 100 Hz. Data from 2 of the 17 participants were excluded from subsequent analysis due to poor quality.runica algorithm in EEGLAB [Following band-pass filtering (0.5–45 Hz), independent component analysis (ICA) was performed with n EEGLAB  in ordert test at the group level.Since head position within the MEG helmet can vary across participants, global field power (GFP) was utilized to provide a measure of the overall activity across all channels . IndividSensor level time–frequency analysis was undertaken by convolution of the data with Morlet wavelets (6 cycles) using the continuous wavelet transform function in MATLAB . The coefficients corresponding to 0.5–45 Hz frequency in the − 200 to 900 ms time window relative to stimulus onset were extracted, and log power was computed as the square of the absolute value of the coefficients. To better understand the event-related spectral changes, the mean log power in the baseline period (− 100 to 0 ms) was subtracted from the log power in the post-stimulus period for every trial within the frequency band. Significance was assessed using a bootstrapping approach by permuting the trial-averaged wavelet power in the congruent and incongruent conditions across participants in each frequency . This enSource level analysis was performed using SPM8  with the forward and inverse modeling steps elaborated in previously published work . Source t test at the group level.To facilitate future translation into point-of-care enabled platforms, concurrently collected EEG data were also analyzed to extract ERPs. Contamination from ocular sources was removed from the EEG signal using an adaptive filtering approach . For thiTo evaluate reliability of the rN400 ERP at the individual level, a machine learning-based approach was undertaken using a two-category support vector machine (SVM) classifier following previously published methods , 50. Bricongruent condition) or semantically unrelated (incongruent condition) to the first word. In particular, in the 300–500 ms post-stimulus interval, there was increased power for the incongruent relative to congruent condition . Key areas included left inferior, middle and superior temporal gyri  and regions encompassing both the anterior and posterior portions of the left inferior frontal gyrus BA 45, 47). Additionally, areas of the right temporal and inferior frontal gyri were also activated. In comparison, no suprathreshold clusters were observed for the reverse contrast of congruent > incongruent  generated through the brain vital sign framework. Using a compressed auditory stimulus sequence comprising both tones and prime-target word pairs, we demonstrated that the resulting rN400 response exhibited features consistent with characteristics previously reported for the N400 response in semantic language paradigms , 18. In The sensor-level temporal effects showed a robust rN400 ERP for processing the incongruent relative to the congruent words Fig. , consistWhile the present study targeted the semantic processing effect indexed by the N400 and accordingly focused on the 300–500 ms window of interest to be concordant with previous literature , 44, othTime–frequency results demonstrated a significant decrease in beta band power in the incongruent condition relative to the congruent Fig. c. These Our results showed left-lateralized activations in the temporal cortices BA 20, 21, 22) as well as inferior frontal gyri BA 44, 45)  as a potential marker of residual functional integrity as well as for tracking rehabilitation progress. Beukema and colleagues reported the importance of including N400 in assessments of DOC patients , while SAdditionally, the robust identification of the N400 effect at the individual level using automated expert-independent machine learning approaches provides additional support for clinical application of this rapid assessment technique. The 89% hit rate in the present study is quite comparable to previous reports—with prior machine learning based analysis reporting results in the 86–92% range , 37 and Despite the promising findings in this study, two main limitations should also be noted. As this is the first study characterizing the rapidly elicited rN400 response within the brain vital sign framework, the focus was on examining its spatiotemporal and neuroanatomical effects and comparing them with known features of the traditional N400 response. However, given the myriad of language- and non-language-based experimental paradigms in which the N400 response has previously been described, it is not feasible to compare the rN400 response to every other traditional paradigm in one study. Rather, the current study focused on comparisons with language-based paradigms, and utilized response features and characteristics that have been identified as commonalities across different studies in order to account for variable modalities and experimental parameters  , 17, 62.In this study, we investigated the spatiotemporal and neuroanatomical features of the N400 response as elicited by the rapid assessment brain vital signs framework. Using both MEG and EEG, our results showed that the rapidly elicited N400 response exhibits characteristics consistent with those reported in traditional semantic language-based N400 paradigms. These characteristics include temporal features showing maximal response within 300–500 ms latency; topographic scalp distribution demonstrating maximal response at the posterior Pz electrode; spectral effects showing reduction in beta band power; and source localization to left-lateralized temporal and inferior frontal areas. With the increasing use of the N400 response in patient assessments for neurological conditions such as dementia and traumatic brain injury, the convergent M/EEG results of the current study provide further support for the possibility of translating the N400 response from research to clinical settings through a rapid assessment framework for evaluating cognitive functions.


The new sepsis definition has increased the need for frequent sequential organ failure assessment (SOFA) score recalculation and the clerical burden of information retrieval makes this score ideal for automated calculation.The aim of this study was to (1) estimate the clerical workload of manual SOFA score calculation through a time-motion analysis and (2) describe a user-centered design process for an electronic medical record (EMR) integrated, automated SOFA score calculator with subsequent usability evaluation study.First, we performed a time-motion analysis by recording time-to-task-completion for the manual calculation of 35 baseline and 35 current SOFA scores by 14 internal medicine residents over a 2-month period. Next, we used an agile development process to create a user interface for a previously developed automated SOFA score calculator. The final user interface usability was evaluated by clinician end users with the Computer Systems Usability Questionnaire.The overall mean  time-to-complete manual SOFA score calculation time was 61.6 s (33). Among the 24% (12/50) usability survey respondents, our user-centered user interface design process resulted in >75% favorability of survey items in the domains of system usability, information quality, and interface quality.Early stakeholder engagement in our agile design process resulted in a user interface for an automated SOFA score calculator that reduced clinician workload and met clinicians’ needs at the point of care. Emerging interoperable platforms may facilitate dissemination of similarly useful clinical score calculators and decision support algorithms as “apps.” A user-centered design process and usability evaluation should be considered during creation of these tools. As electronic medical records (EMRs) have propagated through the US health care system, they have brought both great promise and great problems ,2. One uAutomation of computer interaction in clinical medicine can take many forms. Automated information retrieval is commonly utilized to generate shift hand-off and inpatient rounding reports, significantly reducing time spent on information retrieval tasks -12. AutoIn March 2016, the operational definition of sepsis was updated to include a change in SOFA score ≥2 compared with baseline (ΔSOFA) . The updThe prospective time-drain imposed by the new definition may not be trivial; previous studies have indicated a time-cost of about 5 min for information retrieval and manual score calculation per patient . ConsequThe goals of this study were to (1) quantify the current time-drain of manual SOFA score calculation and (2) describe the user-centered design process and usability evaluation of an EMR-integrated real-time automated SOFA score calculator interface.This study was performed at Mayo Clinic Hospital, St Marys Campus in Rochester, Minnesota. The study protocol was reviewed and approved by the Mayo Clinic Institutional Review Board.Internal medicine residents were observed calculating baseline and current SOFA scores during their medical intensive care unit (ICU) rotation over a 2-month period. Residents utilized Mayo Clinic’s locally developed EMR for data retrieval. The instrument  utilized to perform the calculation was at the clinician's discretion. Total calculation time and calculation instrument were captured for each observation. The total time-cost was calculated using average task completion time, assuming one SOFA score calculation or patient day, and extrapolated to the total number of patient medical ICU days at St Marys Hospital in Rochester, MN during a 1-year period.The user interface was designed using an agile development process involving stakeholders from critical care medicine and information technology. Agile software development is a user-centered design process where programs are built incrementally in many short development cycles. These development cycles are analogous to plan-do-study-act cycles utilized in clinical quality improvement. In contrast with traditional “waterfall” linear software development, end-user testing and feedback is performed during each agile developmental cycle rather than during the last phase of the project. Agile software development utilizes close collaboration between developers and end users to guide improvements during each cycle—this feature allows early customization of the user interface (UX) to meet the clinician end user’s information needs. Close involvement of clinician end users throughout the development process has been shown to improve usability and end-user utilization of the resulting product ,27.The algorithm underlying the SOFA score calculator was previously validated for daily score calculation  and updaThe final UX was evaluated with the Computer Systems Usability Questionnaire administered through REDCap ,29. The All statistical analysis for study was performed with R version 3.3.1 . For theP<.001). Most participants  manually entered data points into a Web-based score calculator; the remainder used a mobile phone app. There was a significant linear association between current hospital day and time to calculate baseline score . If we extrapolated the time-cost to an entire year within our institution’s 24-bed medical intensive care unit, the cumulative time required for one extra manual SOFA score calculation for each patient day (6770 patient days) would be about 116 (64) hours. This amounts to almost 5 extra hours of work per ICU bed distributed among our medical intensive care clinicians.Fourteen internal medicine residents were observed calculating 35 baseline and 35 current SOFA scores for patients admitted to the medical ICU under their care. The overall mean (SD) calculation time was 61.6 s (33). The time required to calculate the current SOFA score was significantly lower than the baseline score  ability to quickly identify when the ΔSOFA≥2 (vs baseline) threshold had been passed; (2) ability to quickly view current, baseline, and previous SOFA scores from the current hospitalization, broken down by SOFA score component; (3) ability to quickly identify when data was missing for each SOFA component and if data was carried forward; (4) ability to quickly identify the source data used for each SOFA component calculation; and (5) high accuracy. Items 3-5 reflect the concerns several stakeholders expressed about the potential for automation bias with this tool . One nonFifty computer systems usability questionnaires were distributed to clinicians who had the opportunity to use the tool in clinical practice during the 2-month period. We received 24% (12/50) responses. The questionnaire was completed by 11% (1/9) residents, 17% (4/24) fellows, and 42% (7/17) attending physicians. A summary of user usability feedback is shown in The first part of our study estimates the time-drain of manual SOFA score calculation with a modern EMR system and describes an attempt to mitigate these inefficiencies with an EMR-integrated automated SOFA score calculator created through a user-centered design process. Our time-motion analysis found that the current time required for manual calculation using a modern EMR has improved compared with a study performed 5 years prior . HoweverThe second part of our study describes the iterative, user-centered design process for an EMR-integrated automated calculator “app” for the SOFA score. Clinician stakeholders worked closely with developers throughout the rapid UX development process. The resulting interface was favorable to clinician end users in all three usability domains assessed .2 DS2-VASc [Several other clinical scores have been automated for clinical practice—examples include APACHE II ,33, APACDS2-VASc , CharlsoDS2-VASc , and earDS2-VASc . These sDS2-VASc . ConsequDS2-VASc ,39-42.Future demand for SOFA score calculation in clinical practice may be dependent on policy from the Centers for Medicare and Medicaid Services (CMS), which is still recommending the use of the previous definition of sepsis outlined in the Severe Sepsis or Septic Shock Early Management (SEP-1) bundle because of concerns about increasing cases of missed sepsis under the new definition ,17,19. CThe pairing of the automated SOFA calculator algorithm with the user-centered UX design may hold advantages over these machine-learning based “black box” algorithms—our underlying algorithm is based on a familiar, well-validated clinical score and the visualization of each SOFA component allows clinicians to “look under the hood” to explore the source data behind each item’s value. The ability to verify the source data within the UX reflected the information needs of our clinician stakeholders identified during the agile software development process. With the “black box” algorithms of artificial neural networks and other machine learning techniques, a comparable level of transparency is not possible. Finally, traditional externally validated clinical scores, like SOFA, may be more generalizable than machine-learning algorithms . The extThe emerging “substitutable medical apps, reusable technology” (SMART) on “fast healthcare interoperability resources” (FHIR) interoperable application platform is a promising avenue to bridge the gap between standalone applications and EMR integration . AdditioThe primary limitation of this study is that the clinician stakeholders are from a single institution and their needs might not match the needs of clinicians elsewhere. However, a similar user-centered design and evaluation process could be utilized at other institutions to create and customize a similar tool. Second, clinician survey response rate was low. We aimed to include residents, fellows, and critical care attending physicians with exposure to the tool to obtain perspectives from a wide variety of clinical roles. However, nearly all survey responses were provided by critical care attending physicians and fellows. The tool appeared to meet the usability needs of these content experts.The incorporation of SOFA scoring into the sepsis definition potentially adds about 1 min per patient  to an intensive care clinicians’ workload—an amount that is compounded when recalculation is performed multiple times daily to confirm if ΔSOFA criteria have been met. This added workload can be eliminated through automated information retrieval and display. To generate the information display for an EMR-integrated automated SOFA score calculator, we utilized a user-centered agile design process that resulted in a user interface with >75% of usability features receiving favorable ratings across the system usability, information quality, and interface quality usability domains. Usability evaluations are important as clinical decision support algorithms are translated into EMR-integrated applications.