Ventilator-induced lung injury and ventilator-induced diaphragmatic dysfunction are major complications in mechanically ventilated patients with acute respiratory failure. Invasive ventilation adds a further burden by increasing the risk of infections. An approach that protects both lung and diaphragm is pivotal. Mirabella and colleagues compared conventional controlled ventilation with a mode that combines several potentially lung-protective properties - non-invasively applied neurally adjusted ventilatory assist - in an animal experiment. This approach seemed to be as effective but potentially more lung-protective. Although the experimental setup and results cannot be translated directly to the clinical setting, they should motivate us to further study this innovative approach. Critical Care, Mirabella and colleagues [In the previous issue of lleagues  studied lleagues . In addilleagues ,4. Both NAVA provides airway pressures proportional to the electrical activity of the diaphragm during inspiration, ensures efficient patient-ventilator synchrony, and maintains the degree of biovariability that corresponds to the actual status of the patient -9. TheseThe (at least) initial use of non-invasive ventilation (NIV) in hypercapnic ARF with respiratory muscle weakness is a well-accepted medical standard; in contrast, its use in hypoxemic failure  is limited because even a very short loss of end-expiratory pressure might lead to significant derecruitment and severe hypoxemia . Combini2O) with neuromuscular blockade in an animal experiment with acid-induced ARF  [Based on the hypothesis that NIV-NAVA  might be equally protective, the authors compared it with conventional invasive mechanical ventilation  . At 6 hoThe authors ascribe these effects to the maintenance of spontaneous breathing, upper airway liberation, and variable breathing pattern. The approach of this study is innovative and, to some extent, challenges the iron law that, in ARDS states comparable to those experimentally induced in this study, intubation and controlled mechanical ventilation are the only appropriate options.The study, though presenting challenging results, has obvious limitations, foremost relating the findings to one well defined, specific intervention. This is true for two reasons. First, the study compares two different modes of mechanical ventilation: volume-controlled mechanical ventilation in paralyzed, deeply sedated subjects and assisted mechanical ventilation applied with NAVA. Second, it compares two different interfaces by which mechanical ventilation is applied: invasive mechanical ventilation via an endotracheal tube and NIV applied via a nasal prong.A group of non-invasive pressure support ventilated animals would have allowed us to better understand and interpret the results, but (as stated by the authors) this was technically not achievable.Before open NIV-NAVA can be considered in the clinical setting, a number of questions presented by the complexity of the topic have to be answered:1. Do the positive effects prevail over a longer period of time? In a setting where positive effects have to persist and side effects might need time to develop their detrimental effects, an observation period of 6 hours is too short.2O underlines the importance of non-prima vista effects of NAVA that might open new treatment options for respiratory failure. If ARF resolves within a short period of time, preservation of tonic activity might be an effective measure. The long-term effect remains to be elucidated. A prolonged phase of induced tonic activity might fatigue the diaphragm and induce secondary respiratory failure [2. Is persistent tonic activity less injurious than the application of PEEP? PEEP has a direct effect on respiratory muscle load, recruitment, and pulmonary gas exchange; it reduces alveolar cycling and influences the respiratory drive . Tonic a failure . The inc3. Are the findings transferable to a more stable severe ARDS and increased respiratory drive? The preservation of spontaneous breathing has marked beneficial effects . HoweverTwenty percent regurgitation in the NIV group would be unacceptable in clinical routine. This finding, however, should be interpreted with caution since the sedation level required to enable the animal experiment might account for this side effect.This experimental study by Mirabella and colleagues offers interesting insights into the potentials of NIV-NAVA . It is eHowever, we would like to state that this study challenges accepted limits or standard of care in several ways. In light of the current standard of routine care in patients who resemble the chosen experimental setup (moderate ARDS), the findings should be weighed carefully before being translated to clinical practice. As noted by the authors themselves, NIV should be restrictively used in patients with hypoxemic respiratory failure, and its application without PEEP cannot be advised at this stage.ARDS: Adult respiratory distress syndrome; ARF: Acute respiratory failure; NAVA: Neurally adjusted ventilatory assist; NIV: Non-invasive ventilation; PEEP: Positive end-expiratory pressure; VIDD: Ventilator-induced diaphragmatic dysfunction; VILI: Ventilator-induced lung injury.MQ consults for companies that manufacture ventilators, including Dräger Medical , CareFusion , and Maquet Critical Care , and is remunerated for these consultations. In 2006, OM participated in a research project at Uppsala University, financed by research grants from Göttingen and Uppsala University and supported by Maquet Critical Care.


Contrast-induced nephropathy is an important cause of acute renal failure. We assess the efficacy of acetylcysteine for prevention of contrast-induced nephropathy among patients undergoing intravascular angiography.We conducted a systematic review and meta-analysis of randomized controlled trials comparing prophylactic acetylcysteine plus hydration versus hydration alone in patients undergoing intravascular angiography. Studies were identified by searching MEDLINE, EMBASE, and CENTRAL databases. Our main outcome measures were the risk of contrast-induced nephropathy and the difference in serum creatinine between acetylcysteine and control groups at 48 h.higher incidence in six of the latter studies). The pooled odds ratio for contrast-induced nephropathy with acetylcysteine relative to control was 0.54  and the pooled estimate of difference in 48-h serum creatinine for acetylcysteine relative to control was -7.2 μmol/L . These pooled values need to be interpreted cautiously because of the heterogeneity across studies, and due to evidence of publication bias. Meta-regression suggested that the heterogeneity might be partially explained by whether the angiography was performed electively or as emergency.Fourteen studies involving 1261 patients were identified and included for analysis, and findings were heterogeneous across studies. Acetylcysteine was associated with a significantly reduced incidence of contrast-induced nephropathy in five studies, and no difference in the other nine (with a trend toward a These findings indicate that published studies of acetylcysteine for prevention of contrast-induced nephropathy yield inconsistent results. The efficacy of acetylcysteine will remain uncertain unless a large well-designed multi-center trial is performed. Contrast-induced nephropathy is a leading cause for acquired acute reductions in kidney function ,2. DespiThe pathophysiology of contrast-induced nephropathy remains incompletely understood. However, current evidence suggests that contrast media induce prolonged vasoconstriction and medullary ischemia coupled with generation of free radicals and oxidative injury to tubular cells -11.Acetylcysteine, a thiol-containing anti-oxidant, has been hypothesized to prevent contrast-induced nephropathy. The potential benefit of acetylcysteine is believed to be mediated by its properties as a scavenger of free-radical species and by increasing the synthesis of nitric oxide, a potent vasodilator, in response to ischemic or other toxic injury in the kidney . Given tWe identified published randomized controlled trials of acetylcysteine for prevention of contrast-induced nephropathy during intravascular angiography using both electronic and manual search strategies. We supplemented this by scanning the reference lists of all identified articles, reviewing selected conference proceedings, and by contacting experts in the field. All languages and types of publications were considered eligible. The comprehensive literature search was initially performed in April 2003 and updated in June 2004 to identify any potential new studies that may have appeared.MEDLINE , EMBASE  and CENTRAL  databases were searched via OVID using an approach recommended for systematic reviews of randomized trials . PubMed Two individuals (SMB and WAG) independently evaluated identified articles for eligibility on the basis of four inclusion criteria: 1) study design , 2) target population (patients undergoing intravascular angiography), 3) intervention  and 4) outcome .Two reviewers (SMB and WAG) independently extracted data from all primary studies fulfilling eligibility criteria. Any discrepancies in extracted data were resolved by consensus. Data extracted included identifying information, focus of the study, details of study protocol and demographic data. The primary outcome measures were the incidence of contrast-induced nephropathy and change in serum creatinine. The secondary outcome measure was requirement for renal replacement therapy. Authors of the studies were contacted for additional information when applicable.et al [Two reviewers (SMB and WAG) independently assessed methodological quality of individual studies. Any disagreements were resolved by consensus. Items used to assess study quality were methods of randomization, any blinding, use of a placebo, reporting of losses to follow-up or missing outcome assessments, and evidence of important baseline differences between the groups -18. An oet al .The presence of heterogeneity can compromise the interpretation and validity of meta-analyses and can result from significant differences in methodology, study populations, interventions, outcomes, or chance . A priorData from all of the selected randomized controlled trials were combined to estimate the pooled odds ratio (OR) with 95% confidence intervals (CIs) using a random-effects model as described by Der Simonian and Laird ,21. The A total of 66 unique citations were identified by our initial search strategy Figure . After tAll the randomized controlled trials were published in the years 2002 through 2004. Tables The definition of contrast-induced nephropathy was variable across studies. Four studies defined contrast-induced nephropathy as a > 44.2 μmol/L increase in serum creatinine from baseline ,29,32,37The reported incidence of contrast-induced nephropathy was variable across studies. Table Table Meta-regression was performed to assess a number of clinical and study quality factors that may have led to heterogeneity across studies. Interestingly, these analyses suggest that the heterogeneity may be partially explained by whether the angiography procedures were performed electively or as emergency, because studies where all enrolled patients were undergoing elective procedures had significantly lower odds ratios than did studies where emergency cases were included .Other meta-regression analyses demonstrated that the heterogeneity could not be accounted for by differences in patient age , baseline serum creatinine , volume of contrast media  or diabetes mellitus . Likewise, heterogeneity was not accounted for by differences in study quality including use of blinding , concealment of randomization , use of placebo  or overall Jadad score .There was some evidence to suggest possible publication bias according to Begg's test  and a trend with Egger's test . Figure Our meta-analysis of 14 peer-reviewed studies of patients undergoing intravascular angiography may lead some to conclude that the administration of acetylcysteine causes a reduced incidence of contrast-induced nephropathy. However, such a conclusion may be premature based on data published to date because our systematic review reveals considerable heterogeneity of findings across trials. Furthermore, our meta-analysis of post-treatment creatinine values does not reveal any truly meaningful difference in serum creatinine levels at 48 h between the acetylcysteine and control groups. Finally, insufficient data are available to allow inferences to be drawn about the efficacy of acetylcysteine on clinically meaningful endpoints such as dialysis, length of hospitalization or mortality.et al that recently received considerable attention, and that rather firmly concluded that acetylcysteine is beneficial [et al, and more directly address the relevance of this heterogeneity in the overall interpretation of study results. Two other meta-analyses have also recently been published, and similarly concluded that acetylcysteine is beneficial; however, these studies also failed to adequately address the issue of the considerable heterogeneity across studies [This meta-analysis has several features that distinguish it from a similar meta-analysis by Birck neficial . First, neficial . Fourth, studies ,42. Coll studies . Many wi studies ,45 make The presence of heterogeneity and/or publication bias can compromise the interpretation of meta-analyses and result in erroneous and potentially misleading conclusions ,43. A stdefinitely efficacious based on data published to date. Our firm conclusion based on this meta-analysis of published trails is that although the data seem quite promising, the efficacy of acetylcysteine has not been definitively proven.There are many parallels between the intravenous magnesium story and our meta-analysis findings for acetylcysteine. The marked heterogeneity of findings across studies, and the finding of funnel plot asymmetry (indicating possible publication bias), ought to be viewed as strong cautionary points against making firm conclusions about the efficacy of acetylcysteine. And while it is true that acetylcysteine is inexpensive, easy to use and has a favorable side-effect profile, it is probably premature to conclude scientifically that it is To isolate potential sources of heterogeneity we performed a meta-regression analysis exploring several clinical and study quality factors. There was no evidence of association between effect size and baseline serum creatinine, volume of contrast media, or diabetes mellitus, all independently identified risk factors for development of contrast-induced nephropathy ,53. HoweFunnel plot asymmetry is often interpreted to indicate publication bias. However, it is important to consider that this asymmetry may also be due to other sources of bias that deserve further examination. In particular, fundamental disparities in study design, inconsistencies in methodological quality and differences in the definition of primary outcomes may have contributed to funnel plot asymmetry. Our meta-regression analysis explored the potential role of several study quality factors, and none were identified as statistically significant predictors of apparent acetylcysteine efficacy across trials. Nonetheless, it is quite possible that other unmeasured study quality factors may have contributed to biased results and accompanying funnel plot asymmetry.Contrast-induced nephropathy continues to be an active subject matter for clinical investigation ,56. A deAll of the above leads us to conclude that while acetylcysteine appears to be safe and inexpensive, its efficacy for the prevention of contrast-induced nephropathy remains unproven. The results of the trials that we reviewed to date should be viewed as early promising evidence of benefit, and suggest that it is now perhaps reasonable to use acetylcysteine in routine care because of its relative ease of use and safety. However, its true efficacy will remain uncertain unless a definitive well-designed multi-center trial is performed. Such a clinical trial will be most relevant if it addresses a priori clinically meaningful endpoints of renal insufficiency, rather than surrogate endpoints based on changes in creatinine levels alone, and further considers stratification on hypothesized important subgroups that may benefit such as those with a low ejection fraction .The authors declare that they have no competing interests.SMB developed the study protocol, conducted literature search, screened articles for eligibility, extracted data, analyzed data, interpreted results, wrote and revised the manuscript. WAG contributed to protocol development, screened articles for eligibility, extracted data, analyzed data, interpreted results, and provided critique of successive drafts of the manuscript. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


A relatively consistent body of research supports an inverse graded relationship between socioeconomic status (SES) and cardiovascular disease (CVD). More recently, researchers have proposed various life course SES hypotheses, which posit that the combination, accumulation, and/or interactions of different environments and experiences throughout life can affect adult risk of CVD. Different life course designs have been utilized to examine the impact of SES throughout the life course. This systematic review describes the four most common life course hypotheses, categorizes the studies that have examined the associations between life course SES and CVD according to their life course design, discusses the strengths and weaknesses of the different designs, and summarizes the studies' findings.This research reviewed 49 observational studies in the biomedical literature that included socioeconomic measures at a time other than adulthood as independent variables, and assessed subclinical CHD, incident CVD morbidity and/or mortality, and/or the prevalence of traditional CVD risk factors as their outcomes. Studies were categorized into four groups based upon life course design and analytic approach. The study authors' conclusions and statistical tests were considered in summarizing study results.Study results suggest that low SES throughout the life course modestly impacts CVD risk factors and CVD risk. Specifically, studies reviewed provided moderate support for the role of low early-life SES and elevated levels of CVD risk factors and CVD morbidity and mortality, little support for a unique influence of social mobility on CVD, and consistent support for the detrimental impact of the accumulation of negative SES experiences/conditions across the life course on CVD risk.While the basic life course SES study designs have various methodologic and conceptual limitations, they provide an important approach from which to examine the influence of social factors on CVD development. Some limitations may be addressed through the analysis of study cohorts followed from childhood, the evaluation of CVD risk factors in early and middle adulthood, and the use of multiple SES measures and multiple life course analysis approaches in each life course study. The adult behavioral lifestyle theory of cardiovascular disease (CVD) describes an adult's lifestyle choices and levels of physiologic risk factors as the primary predictors of CVD risk -3. This A force behind the interest in the impact of early-life conditions on adult health is the fetal origins (Barker) hypothesis. This hypothesis, which has been met with considerable support and criticism, posits that poor nutrition during fetal and early infant development  can increase risks for adult disease. While the dominance of the adult lifestyle model of chronic disease development may not be threatened by evidence for the fetal origins hypothesis, a reconsideration of the primary importance of adult behaviors and risk factors is underway.A life course approach to chronic disease proposes that the combination, accumulation, and/or interaction of the social environments and biological insults experienced throughout the life course impact current and future events, environments, and health conditions and thus ultimately impact adult health ,14. VariThis review describes the major groups of conceptual life course SES models, and then categorizes and summarizes studies that examine the associations between life course SES and CVD risk. Studies are grouped by the basic life course design utilized; summaries include methodologic critiques and descriptions of certain key studies. Evidence supporting each conceptual life course model is considered and future research directions are discussed.The different extant hypotheses on the influence of life course SES on CVD can be grouped into four broad conceptual models: the latent effects, pathway, social mobility, and cumulative life course models. Most studies reviewed tested the influence of life course SES on CVD outcomes via the operation of one or more of these models.The "latent effects" life course conceptual model hypothesizes that adverse early life experiences increase the risk of CVD in later life, independent of intervening SES, lifestyle, or traditional CVD risk factors. Power & Hertzman (1997) describe a latent effects model wherein certain early life events may have strong independent effects on adult health . Kuh andIn this life course model, early life events and environments influence later life experiences, opportunities, and health risk factors. Hertzman et al. 2001) propose a developmental process linking early-life psychosocial environments with adult health risk via pathway effects, wherein early experiences place an individual onto a certain "life trajectory," eventually impacting adult health . Similar01 proposWhile a pathway life course model is intuitively appealing, its operation is difficult to test empirically. Life course studies typically collect information on participants at two or three time points, which does not permit the continuous, lifelong operation of pathway effects to be observed.Social mobility theories all hypothesize that SES mobility across the life course impacts adult health, although the different proposed theories posit different health effects. Forsdahl (1978) hypothesized that deprivation in early life followed by later affluence combine to produce elevated CHD mortality risk, partly via elevation of adult cholesterol levels . Others A cumulative SES life course model hypothesizes that psychosocial and physiological experiences and environments during early and later life accumulate to influence adult disease risk. Davey-Smith et al. 2002) suggest that if factors operating at different life stages are combined, large differences in CVD risk will be observed . Kuh et 02 suggesWe conducted a MEDLINE search using keywords and MeSH terms related to SES, life course, early life, longitudinal studies, CVD and CVD risk factors. References identified and books on life course research were also examined for study citations. Inclusion criteria were: (1) publication date between January 1966 and July 2003; (2) SES or related measures as independent variables; (3) outcomes of subclinical CHD, CVD morbidity and/or mortality, or traditional CVD risk factors. Behavioral risk factors were limited to: adult diet, physical activity, alcohol consumption, and smoking. Physiological outcomes were: measures of obesity, blood pressure, intima-media thickness, fibrinogen, insulin resistance, dyslipidemia, and lung function. Ecologic studies, studies primarily evaluating the fetal origins hypothesis, and studies only examining the impact of birth weight, height, upper leg length, patterns of growth, household crowding, geographic mobility or numbers of siblings were excluded. Forty-nine studies met the inclusion criteria.Quantitative summarization of the study findings is problematic due to varied study populations, SES measures and CVD outcomes evaluated, time points evaluated, and designs utilized. Moreover, a tally approach to summarizing across studies based on statistical significance can be misleading due to the different strengths, weaknesses, power and biases of each study (p. 671) . SummariStudies were categorized by their life course study design(s) and study question(s) into four groups: early SES → outcome, early SES → risk factor, social trajectory, and cumulative SES studies. Several studies appear in multiple categories, as they employed more than one of these designs. Table These studies examined the effect of childhood and/or adolescent SES on risk of adult CVD , CVD death, incident/fatal stroke) -56 and tTable For studies with CHD and stroke outcomes limited to early-life SES  almost all included a point estimate consistent with an inverse association. However, in adjusted analyses, authors of only one study with a CHD-related outcome and fewer than half the studies of CVD mortality reported inverse adjusted associations. Thus, the existence of a "direct effect" of early-life SES after adjusting for adult risk factors was not strongly supported.To prevent statistical confounding by adult conditions, most studies employed statistical models that adjusted the association between childhood SES and adult CVD risk for adult SES and behavioral/ physiological CVD risk factors. This may be an over-adjustment, as certain risk factors  are part of the pathways through which low childhood SES may influence CVD risk. Little information is usually available on how participants' early-life SES may have influenced levels of adult CVD risk factors. Additionally, if unknown variables influence both the distribution of a CVD risk factor adjusted for and the distribution of the outcome measure, then adjustment will result in an incorrect partitioning of the total effect of early-life SES into "direct" and "indirect" components -59. ThusSome studies examined and qualitatively compared the effects of adjustment for different classes of CVD risk factors. Gliksman et al. (1995), for example, analyzed the association between father's occupational class and adult CVD in a series of models adjusting for different classes of potential mediators or confounders. This allowed for a more complete description of the impact of adult environment, behavior, and physiologic risk factors versus the latent impact of early life socioeconomic factors . StudiesLife course studies in the early SES → risk factor group evaluated the influence of early- and/or mid-life SES or living conditions on later-life behavioral or physiologic CVD risk factors ,52,61-73Table As with the early SES → outcome studies, concerns that lack of adequate adjustment or over-adjustment may lead to biased estimates are germane to this group of studies. The issue of covariate adjustment is complex in these studies, given that many CVD risk factors are considered. Certain physiologic risk factors  may be linked to early-life SES through latent physiologic effects of negative childhood exposures, continuous exposure to negative physiologic stimuli, or other physiologic or life course pathway mechanisms ,63,70,74Studies evaluating the social mobility life course model typically considered the impact of inter-generational or intra-generational social mobility on CVD and CVD risk factors ,73,75-79Table Four studies examined differences in CVD risk between stable low-SES trajectory and stable high-SES trajectory individuals ,44,75,79In these studies the unit of analysis is a trajectory, permitting the impact of change over time to be examined. However, the socioeconomic trajectories in most reviewed studies were limited to two time points, and groups compared tended to share the same SES at one of these time points. These similarities may partly explain why seven of ten studies did not report an association between social mobility and risk of CVD risk factors or events. Social trajectory studies incorporating SES at three or more time points allow for the analysis of more informative trajectories than studies evaluating SES at only two points . Yet, evThese studies tested the operation of the cumulative life course conceptual model, typically by summing the number of times participants experienced unfavorable SES situations during early, middle or later life, and creating SES indices representing the accumulation of these experiences ,79,81,82Table Davey-Smith et al. (2002) employed a unique cumulative SES measure, combining early and later-life occupational class experience with the CVD risk factors of smoking and heavy alcohol consumption . They reOnly a large cohort study of Norwegians reported a statistically significant supra-multiplicative interaction between early- and later-life SES on risk of CVD . AnotherThe reported associations between cumulative SES and CVD risk are more consistent than those reported in the other life course study designs. However, three of the seven studies evaluated were based on the same cohort ,81,82. CCertain general limitations and assumptions of life course SES studies should be considered. First of all, SES is a theoretical construct operationalized using various measures  that tap into different components of this construct. Despite several proposed SES evaluation schemes -85, therMost life course studies used retrospective cohorts or a case-control design, relying on participants' recall of early life SES. There has been little systematic evaluation of the validity of recalled early life circumstances or of the potential for such recall errors to bias associations. In studies directly comparing the impact of childhood and adult SES on adult CVD risk, greater error in childhood (vs. adult) SES measures may underestimate the true impact of child SES ,87. AddiMost studies were limited to white males. While the number of studies including women has increased in recent years, minority groups remain underrepresented in most life course studies. These groups may interact differently with the economic and/or social systems of the majority group; there are also established associations between minority status, low SES, and increased CVD risk ,84,85. TThe majority of the early SES → outcome group studies' results describe an inverse association between early life SES and risk of adult CHD, non-fatal MI, and CVD mortality. Similarly most early SES → risk factor studies suggest that low early-life SES negatively impacts levels of adult CVD risk factors. Most studies reported relationships between lower early-life SES and elevated alcohol intake, BMI/WHR, and insulin resistance, as well as decreased leisure physical activity. Together, the early SES → outcome and early SES → risk factor studies support the hypothesis that low early-life SES is inversely associated with adult risk of CVD. However, support for the hypothesis of a "direct effect" of early-life SES on risk of CVD mortality is equivocal as findings were less consistent after risk factor adjustment. Additionally, reported associations between early-life SES and adult health behaviors detract from the evidence supporting a latent effects life course model, as they suggest that CVD risk may be driven by learned behaviors.The operation of social chains of risk or life trajectories described by a pathway life course model are difficult to observe or test, since almost all early SES → risk factor studies consider only two points during the life course. However, significant associations between early-life SES and the adult risk factors suggest behavioral, psychosocial or environmental links that may be best explained as a pathway effect. As described below, the pathway model will need further examination through the use of series of linked studies.While nine of 10 social trajectory studies reported some relationship between inter- or intra-generational social mobility and CVD-related outcomes, only four were identified as providing evidence in favor of a social mobility hypothesis. Conversely, most studies comparing stable low- and high-SES trajectory groups reported markedly increased CVD mortality among the low-SES group, with many socially mobile groups having a CVD risk between the stable high and low groups. Determining whether these associations are a function of social mobility, or whether they are due to exposure to low SES at some point in the life course and not to mobility, is problematic. Future studies should focus on differentiating between the influences of cumulative SES and social mobility.Of the conceptual models discussed, the cumulative life course model was the most consistently supported. However, the weight of these findings is limited as much of the data came from one cohort ,60,61. AResearchers have noted the limitations of life course SES study designs examining only one potential pathway linking SES and CVD. Accordingly, recent studies tend to use a combination of SES measures, CVD risk factor and/or outcomes and life course study designs ,52,53,68As modern life course cohorts are followed from childhood, longer prospective studies or series of cross-sectional studies that evaluate associations between early-life experiences and risk factor levels at several time points may provide the opportunity to observe the operation of pathway life course effects. For example, two studies in the early SES → risk factor group ,90 compaIndividuals' socioeconomic environments may impact their CVD risk factor levels and CVD risk. Community socioeconomic conditions may influence individuals' ability to engage in leisure physical activity or eat a healthy diet -97. SomeLife course SES studies have generally failed to consider the length of exposure to the various socioeconomic conditions measured. As this may influence the impact of negative SES experiences on adult health, future cumulative life course studies may benefit from evaluating the effect of length of exposure into their indices.The wide range of populations, analysis designs, exposures, and outcomes used in the life course studies reviewed precludes a simple, quantitative analysis of the impact of life course SES on CVD risk. Nevertheless, the results thus far modestly support the existence of life course SES effects on risk of adult CVD. The cumulative life course model is more consistently supported by extant studies than other models. However, the different methodologic issues of each study design make direct comparisons of the relative support for each conceptual model difficult. Analyses utilizing multiple life course designs within the same study offer the best approach to testing which theories best describe the links between life course SES and CVD risk. The inclusion of minority participants, different SES measures, and data from early and middle adulthood in large, prospective, mixed-design studies will allow more informed and generalizable statements to be made about the impact of life course SES on adult disease risk. While this area of research needs methodologic refinement, it offers a promising and informative perspective from which to understand the development of chronic disease.The author(s) declare that they have no competing interests.R. A. Pollitt conducted the literature search, reviewed and categorized the articles and had primary responsibility for writing the manuscript. K. M. Rose assisted in the categorization and summarization of the papers reviewed, and helped to revise the manuscript in response to the reviewer's comments. All authors participated in interpreting the studies' results and preparing the methodologic criticism, provided input on the various drafts, and read and approved the final manuscript.The pre-publication history for this paper can be accessed here:SES – CVD life course studies using an early SES → outcome designClick here for fileSES – CVD life course studies using an early SES → risk factor designClick here for fileSES – CVD life course studies using a social trajectory designClick here for fileSES – CVD life course studies using a cumulative SES designClick here for file


There is no clear definition of osteogenesis imperfecta (OI). The most widely used classification of OI divides the disease in four types, although it has been suggested that there may be at least 12 forms of OI. These forms have been named with numbers, eponyms or descriptive names. Some of these syndromes can actually be considered congenital forms of brittle bones resembling OI (SROI).A review of different syndromes with congenital brittle bones published in the literature is presented. Syndromes are classified in "OI" (those secondary to mutations in the type I pro-collagen genes), and "syndromes resembling OI" . A definition for OI is proposed as a syndrome of congenital brittle bones secondary to mutations in the genes codifying for pro-collagen genes (COL1A1 and COL1A2).A debate about the definition of OI and a possible clinical and prognostic classification are warranted. OI tarda has also been sub-divided in "gravis" and "levis" [Besides brittle bones, all other clinical characteristics of osteogenesis imperfecta (OI) are variable, and even different members of the same family may present with a dissimilar degree of severity . Severit "levis" . This cl "levis" . Some of "levis" ,6. The m "levis" ,8. In fa "levis" -11. Some "levis" -14, whil "levis" , Bruck s "levis" ), and ot "levis" , OI with "levis" , OI with "levis" , osteopo "levis" ,21. FollHere, syndromes with congenital brittle bones are divided in osteogenesis imperfecta (those secondary to mutations in the type I pro-collagen genes) and syndromes resembling OI The most common mutation causing OI type I causes a reduction in the production of otherwise normal type I collagen secondary to the effect of a null allele mutation. Patients often have normal stature, and a slightly low stature does not preclude the diagnosis of type I OI. "Type I OI" is not a synonymous of "mild OI". Individuals may have few or no fractures, mostly during the first years of life or even at birth , or numeThese individuals typically have short stature, bowing of long bones, and vertebral fractures. Scoliosis and joint laxity may be present. Patients with this form of OI are generally able to ambulate, but they may require aids for walking. Based in the presence of DI, moderate OI has been sub-divided in two forms, "a" and "b" . These pThese patients have triangular face, product of an enlarged head and under-development of the facial bones. They also have chest deformities, markedly short stature, and severe deformities of the long bones, vertebral fractures, and scoliosis. They are frequently wheelchair-bound, although some are able to walk with aids. Prenatal diagnosis is hard but sometimes possible using ultrasonography . Long boIn this form of OI, most newborns do not survive the perinatal period. Causes of death are malformations or hemorrhages of the central nervous system , extremeDescribed in one infant  who diedTwo boys  and a giFirst described by Bruck et al in 1897 in an adult patient , in thisThis form of SROI was first described in three families in 1972 . Other rTwo other forms of SROI with ocular involvement have been described: one variant with optic atrophy, retinopathy, and severe psychomotor retardation , anotherOriginally published as "type V OI" . PatientThese patients may also have calcification of the interosseous membrane between the radius and ulna, determining a clinical sign, as affected individuals are unable to pronate and supinate the forearm. The radial head may be dislocated. Patients with this syndrome have white sclera and no DI. Mutations in the pro-collagen genes could not be identified so far. Inheritance appears to be autosomal dominant, with variable penetrance.Undistinguishable from moderate to severe OI on a clinical basis, this rare form of SROI , has beeA particular form of SROI with short humerus and recessive inheritance was described in a First Nations community of Quebec, and published as "type VII OI" . The indA definition for osteogenesis imperfecta is proposed based on the presence of type I pro-collagen mutations. Inclusion of related syndromes with unidentified mutations should be considered as SROI until further defined. Different forms of syndromes with congenital brittle bones are reviewed. A debate about the definition of OI and a possible clinical and prognostic classification are warranted.OI Osteogenesis ImperfectaSROI syndromes resembling osteogenesis imperfectaDI Dentinogenesis imperfectaNone declared.The pre-publication history for this paper can be accessed here:


Whiskers don't fossilize, so it's hard to say when they first evolved. But it's quite likely they emerged along with mammals, over 200 million years ago. To elude the eye (and feet) of ungainly dinosaurs, it's thought these shrew-like prototypes foraged at night and sought refuge underground, where the sensory advantages of whiskers would come in handy. Nocturnal animals use whiskers much like the blind use walking sticks: to navigate their surroundings, explore close objects, and avoid running into things.Whiskers, or vibrissae, connect to nerves, blood vessels, and muscles. These special connections allow rats, for example, to actively “whisk” the surface of objects and discern fine differences in texture, just as we move our fingertips along a surface to pick up details. In the wild, whisking helps rats navigate unfamiliar terrain to find food. But how does the brain know what the animal is touching?Rat whiskers scan surfaces in a rhythmic motion that excites sensory receptor cells embedded in their whisker pad. Receptors in each whisker shaft are innervated by several hundred “first-order neurons” that relay sensory signals to second-order neurons in the brain stem, then on to third-order neurons in the thalamus, and finally on to the cortex, where sensory stimuli are integrated in cell clusters called barrels.Ehsan Arabzadeh, Erik Zorzin, and Mathew Diamond work with rats to investigate how sensory receptors extract fundamental features from complex and diverse stimuli to encode texture. Not much is known about how receptor and cortical neurons respond to active whisking along irregular surfaces, though responses to simple stimuli  suggest that neurons might represent texture by encoding kinetic features of whisker vibrations, in particular, velocity. In a new study, Diamond and colleagues investigate the connection between textures, whisker vibrations, and neural codes: do distinct textures produce distinct vibrations? If so, how are these vibrations encoded and reported?The authors first collected kinetic data of whiskers moving across different textured surfaces. Stimulating cranial nerve VII of anesthetized rats (the motor nerve) generated whisking movements akin to those seen in conscious rats; the kinetics of these movements and the vibrations of the whisker shafts were measured under different conditions, including no contact with objects (“free whisk”), contact with smooth objects, and contact with various grades of sandpaper. These vibrations were then “played back” to other rats, while measuring the neuronal activity at two critical stages in the sensory pathway: the first-order neurons that innervate the whiskers and the barrel cortex neurons that integrate the incoming signal.Altogether, the authors collected a neural dataset consisting of first-order recordings, barrel cortical cluster recordings, and simultaneous paired recordings from both sites, all in response to playback of the library of texture-related vibrations. This approach afforded the opportunity to directly compare encoding of information at both levels in the sensory pathway. These recordings show, the authors argue, that temporally distinct firing patterns in the trigeminal ganglion (the cell bodies of the first-order neurons) and cortex captured the kinetic features of the texture-induced vibrations. Each texture's “kinetic signature” is encoded by a characteristic, temporally precise firing pattern associated with whisker movement. Compared to free whisking, coarse sandpaper produced irregular bursts of high and low velocity, and both first-order and cortical neurons fired far more impulses for coarse sandpaper than for free whisks. The authors then used stimuli consisting of random velocities to uncover the “tuning curves” of neurons, and simulations showed that these neuronal tuning curves could perfectly predict the real neural responses to textures.Noting the close match between the simulated and natural responses, Diamond and colleagues conclude that the texture-induced firing patterns observed in the first-order and cortical neurons suggest that neurons selectively encode elemental kinetic features—namely, high velocity—to tell rats what they're whisking. This selectivity allows even a single whisker to transmit significant bits of texture-specific information to the brain. Interesting as rat whisking may be, these findings have relevance beyond the world of whiskered beings, shedding light on the underlying neural processes that translate touch into recognition.


Most patients with non-small cell lung cancer who initially respond to gefitinib or erlotinib (tyrosine kinase inhibitors) ultimately develop resistance and disease relapse. What is the mechanism for this resistance? Uncontrolled proliferation of tumor cells is a hallmark of cancer. In many types of cancer, mutations in genes that activate cellular signal transduction pathways contribute to enhanced proliferation and survival of cancer cells. One well-characterized example is mutation in tyrosine kinases, enzymes that regulate the growth and survival of cells. Tyrosine kinase activity is tightly regulated in normal cells, but is dysregulated due to mutation in some cancers, including lung cancer, resulting in enhanced proliferation and survival of cancer cells. The tyrosine kinases are attractive candidates for molecularly targeted therapy in cancer, because cancers become dependent on growth signals from the mutant tyrosine kinases. Tyrosine kinases require ATP for their enzymic activity, and thus small molecules that mimic ATP can bind to mutant kinases and inactivate them.BCR-ABL gene rearrangement [The paradigm for tyrosine kinase inhibition as treatment for cancer using small-molecule inhibitors was first established in the context of chronic myelogenous leukemia (CML) associated with the angement . Imatiniangement , and alsangement .PDGFRB [PDGFRA [KIT [Imatinib is also a potent inhibitor of the ARG, KIT, PDGFRA, and PDGFRB tyrosine kinases. As a consequence, there have been additional dividends from the United States Federal Drug Administration approval of imatinib for treatment of BCR-ABL-positive CML. For example, imatinib is effective in treatment of chronic myelomonocytic leukemia with gene rearrangements that constitutively activate PDGFRB , of hype [PDGFRA , and of FRA [KIT  .epidermal growth factor receptor (EGFR) in patients with NSCLC that are associated with clinical response to the small-molecule EGFR inhibitors gefitinib (Iressa) or erlotinib (Tarceva) [More recently, this paradigm has been extended to treatment of non-small cell lung cancer (NSCLC). Several mutations have been identified in the context of Tarceva) ,8,9, incTarceva) ,8,9. TheBCR-ABL kinase domain itself, including T315I [As might have been anticipated in treatment of cancer with any single agent, resistance to small-molecule tyrosine kinase inhibitors has emerged as a significant clinical problem. This was first appreciated in patients with CML treated with imatinib whose tumors developed resistance, and has been most extensively studied in that context. Although there are many potential mechanisms for development of clinical resistance, most cases of imatinib-resistant CML are due to point mutations in the ng T315I ,11. Siming T315I ,12. Thesng T315I ,14.PLoS Medicine, Pao and colleagues have identified acquired mutations in patients with NSCLC that appear to explain clinical resistance to gefitinib or erlotinib [In an elegant new study in rlotinib . The mecStructural models of EGFR provide structural insights into these biological data. A ribbon structure of erlotinib bound to the EGFR kinase domain  shows thKRAS alleles that have previously been shown by these same authors to confer resistance to these inhibitors [These observations provide convincing evidence that, at least in some patients with NSCLC, resistance to gefitinib or erlotinib can be attributed to acquisition of a T790M mutation in the context of EGFR. However, three additional patients with clinical resistance to gefitinib or erlotinib did not have the T790M mutation, nor did they have mutant It will be important to identify alternative small-molecule inhibitors for the T790M resistance mutation. Structural data suggest that one compound, lapatinib, may subserve this purpose , but it Pao and colleagues' superb study also highlights several important points that may guide development of kinase-targeted therapies in the future. It is clear that, to the extent that small-molecule kinase inhibitors are effective as single agents in treatment of cancer, resistance will develop. Furthermore, based on previous experience, some of these patients are likely to harbor acquired point mutations in the target kinase that confer resistance. Resistance mutations identified via in vitro screens have shown a high degree of correlation with those that develop in vivo, as shown in screens for imatinib-resistant BCR-ABL mutants  and PKC4These findings also emphasize the critical need for re-biopsy of patients with cancer treated with molecularly targeted therapies at time of relapse. Tissue acquisition is more challenging in solid tumors than for hematopoietic malignancies, and may entail risk. Nonetheless, it is clear that data derived from such analyses will be essential to inform approaches to improving therapy for NSCLC and other solid tumors.


Sexual minority women disproportionately engage in heavy drinking and shoulder the burden of alcohol dependence. Although several intensive interventions are being developed to meet the needs of treatment-seeking sexual minority women, there remains a lack of preventive interventions to reduce drinking and its consequences among women not yet motivated to reduce their alcohol consumption.We aimed to examine the feasibility and efficacy of reducing alcohol-related risks via personalized normative feedback (PNF) on alcohol use and coping delivered within LezParlay, a social media–inspired digital competition designed to challenge negative stereotypes about lesbian, bisexual, and queer (LBQ)–identified sexual minority women.Feasibility was assessed by examining engagement with LezParlay outside the context of an incentivized research study, assessing the characteristics of the LBQ women taking part, and examining the competition’s ability to derive risk-reducing actual norms as well as levels of acceptability and perceived benefits reported by participants. Intervention efficacy was examined by randomizing a subsample of 499 LBQ alcohol consumers  already taking part in the competition to receive sexual identity–specific PNF on alcohol use and coping, alcohol use only, or control topics over only 2 rounds of play. Changes in alcohol use and negative consequences were examined 2 and 4 months after the delivery of treatment PNF.P=.003; P<.001), peak drinks , and negative consequences  relative to those who received PNF on control topics at the 2-month follow-up. However, at the 4-month follow-up, reductions in alcohol consumption outcomes faded among those who received alcohol PNF only , whereas they remained relatively robust among those who received PNF on both alcohol use and coping . Finally, participants found the competition highly acceptable and psychologically beneficial as a whole.A total of 2667 diverse LBQ women played ≥1 round of LezParlay. The competition attracted large numbers of moderate and heavy drinkers; however, risk-reducing actual norms could still be derived from competition rounds and featured in PNF. Efficacy results revealed that drinkers who received PNF on alcohol use and both alcohol use and coping had similar reductions in their weekly drinks (The LezParlay competition was found to be a feasible and efficacious means of reducing alcohol-related risks in this population. Our findings demonstrate the utility of correcting sexual identity–specific drinking and coping norms to reduce alcohol-related risks among LBQ women and suggest that this approach may also prove fruitful in other stigmatized health disparity populations. To engage these populations in the real world and expand the psychological benefits associated with PNF, our findings also point to packaging PNF within a broader, culturally tailored competition designed to challenge negative group stereotypes.ClinicalTrials.gov NCT03884478; https://clinicaltrials.gov/ct2/show/NCT03884478RR2-10.2196/24647 Seeking to address this void, this study evaluates the degree to which an evidence-based personalized normative feedback (PNF) intervention embedded within a culturally tailored digital competition can engage LBQ-identified sexual minority women and reduce their alcohol-related risks.Relative to women who identify as heterosexual, experience only opposite-sex attractions, and only have sex with men, research has reliably documented more frequent and intense alcohol consumption -3, as weConsistent with the sexual minority stress model , extant rite of passage ) for the randomized controlled trial (RCT). As players completed this round, a subsample of 500 LBQ drinkers meeting the eligibility criteria were invited to take part in an evaluation study wherein they were incentivized to play subsequent rounds and complete a feedback survey following the competition. A total of 1337 LBQ women completed the round with 912 users covertly screened for eligibility based on their responses to round questions about alcohol use  and other app data  before the 500 spots in the evaluation study were filled. As described in greater detail elsewhere , at the Human subjects approval for this research was granted by the Loyola Marymount University institutional review board (protocol #LMUIRB2018SU14) on August 14, 2018. All procedures  were in Data collected by Google Analytics and the application examined the total number of users who signed up to participate in the LezParlay competition and detailed users’ average number of logins, number of rounds completed, and most visited areas of the app.All users reported their sexual identity and relationship status at competition sign-up. Age in years, race, and ethnicity were also reported by the evaluation study participants at the point of study enrollment.Three items modeled after the Quantity, Frequency, Max measure  assessedUsers’ own weekly drinks, peak drinks on one occasion, and negative consequences in the past 2 months were assessed using items that paralleled norm items  at the same time points and presented the same response options .Interpersonal stigma exposure was assessed at T1 with two items adapted for the in-game context from a widely used measure of sexual minority stigma : (1) “Dudid not like at all (rating=0) to liked very much (rating=5). Total acceptability scores were computed by summing the ratings.The postcompetition feedback survey prompted study participants to rate numerous aspects of the competition  on Likert-type scales ranging from yes in response were invited to enter text describing their perceived benefits.A single item in the feedback survey asked evaluation study participants to select yes or no in response to the question, “Did you find taking part in LezParlay to be psychologically beneficial?” Those selecting A final free-response question asked evaluation study participants to share any ideas they had for ways in which LezParlay could be improved .Descriptive statistics examined the level of engagement with the LezParlay app , initial levels of alcohol use among players, competition-derived actual norms for treatment topics, competition acceptability among drinkers taking part in the RCT, and the proportion of drinkers taking part in the RCT reporting perceived psychological benefits. Qualitative responses to items assessing the perceived benefits associated with LezParlay and ideas for improvement were examined using a generic inductive qualitative coding approach ,50. Thist tests). One-way ANOVAs and chi-square tests also established conditional equivalency for demographic characteristics, interpersonal stigma, perceived alcohol use norms, and alcohol use behaviors assessed at T1. Examination of attrition suggested that missingness was random rather than systematic. As such, 3 multilevel models, each with maximum likelihood estimation to deal with data missing at random, a random intercept component, and an unstructured covariance matrix, were conducted in SAS (version 9.4) to assess the effects of treatment PNF  on respective changes in weekly drinks, peak drinks, and negative consequences relative to control PNF. In all 3 models, predictors included study condition  and time (T2 and T3 vs T1). To determine whether there were changes in drinking outcomes over time related to PNF treatment, condition × time interaction terms were included in each model. Covariates also included in the models were age, sexual identity , race (White vs non-White), ethnicity (non-Hispanic or Latino vs Hispanic or Latino), relationship status (single vs in a relationship or married), and exposure to interpersonal LBQ stigma. Post hoc Tukey tests were then conducted to determine the nature of significant condition × time effects.Preliminary analysis of RCT data examined the distributions of alcohol-related variables, the nature of missing data, and the characteristics of participants lost to follow-up . The LezParlay web application also recorded 54,072 total page visits among logged in users, with the most frequented sections of the app devoted to browsing the social media–inspired profiles of other users, followed by playing monthly rounds, viewing detailed results , and viewing leaderboards.Yes, of the 1337 LezParlay users who completed the round where alcohol use was first assessed, 254 (19%) reported no alcohol consumption or light drinking (≤2 drinks per week), and 346 (25.88%) reported moderate drinking (3-7 drinks per week and ≤3 drinks on any day). Notably, ≤7 drinks per week and ≤3 drinks per day are the upper limits for low-risk drinking among women, as defined by the National Institute on Alcohol Abuse and Alcoholism , as thes497=4.48; P<.001) and non-Hispanic White . Attrition, in this case, was considered random rather than systematic, given that the average participant in the study was both younger and non-Hispanic White, and attrition was not significantly associated with any other study variables. Beyond attrition, there were no other missing data among participants. As shown in Retention in the RCT was adequate, with 80.2% (400/499) of the evaluation study participants retained at T2 and 71.3% (356/499) at T3. Participants lost to follow-up were younger . Finally, participants in both treatment PNF conditions significantly decreased the negative consequences they experienced relative to controls from T1 to T2 and from T2 to T3.As presented in liked and liked very much . receiving detailed results each round . The exploratory 1-way ANOVA and correlational analyses also determined that acceptability ratings were not significantly associated with participants’ study condition  or baseline measures of alcohol outcomes .Overall, drinkers in the evaluation study found the LezParlay competition to be highly acceptable, with the average participant rating competition aspects between Of the 356 participants who completed the feedback survey, 331 (93%) reported finding the LezParlay competition to be psychologically beneficial. Furthermore, 85.5% (283/331) of the participants that indicated benefits entered text to describe the experienced benefits. Qualitative coding resulted in 6 common categories of benefits reported by participants: knowledge and social comparison, community connection and identity strength, stigma reduction, introspection and self-confrontation, entertainment and fun, and mood enhancement. Notably, although benefits associated with social comparison and self-confrontation in the domain of drinking may be experienced in a traditional PNF alcohol intervention, benefits associated with community connection and identity strength, stigma reduction, entertainment, and enhanced mood and outlook would not be experienced in the context of traditional PNF. Presumably, these extra psychological benefits described by participants were related to LezParlay’s social media–inspired web-based community features, the broad challenging of negative LBQ stereotypes via PNF, and the competition-fostering constellation of game mechanics.guess question screen rather than on a previous screen .In response to the optional item inquiring as to how LezParlay could be improved, 47.5% (169/356) of participants submitted a total of 307 individual ideas for improvement. The most frequently submitted ideas revealed that participants most commonly desired a native (iOS and Android) smartphone app for the competition ; more frequent rounds  with faster results delivery ; increased opportunity for interaction between players ; increased ease of inviting friends and the ability to earn bonus points for referring friends ; the ability to go back and change previously submitted guesses or point wagers before a round closing ; the connection of results to informational articles or community resources ; additional questions about race, gender identity, and sexual identity–based biases within the community ; worldwide promotion and additional results comparing the behaviors and experiences of LBQ players in different countries or regions ; and the ability to see the community thumbnail photo collage of LBQ users being guessed about on the LezParlay leveraged gamification and deep cultural adaptations to deliver a PNF alcohol intervention to LBQ women, a difficult-to-engage population for whom alcohol-related risks are high, but efficacious evidence-based intervention and prevention programs are lacking ,52. Reflbooster to alcohol PNF, further reinforcing the idea that LBQ peers do not drink as much as one previously thought. Thus, although efficacy findings from this initial trial are promising and suggest that both alcohol and coping PNF are beneficial, additional research will be needed to fully understand the mechanisms  by which coping PNF influences drinking in this population.This novel approach to PNF intervention also demonstrated efficacy in reducing drinking and its negative consequences. Relative to LBQ drinkers randomized to receive PNF on control topics in the competition, those who received treatment PNF on drinking or both drinking and coping similarly and substantially reduced their weekly drinks, peak drinks consumed on one occasion, and number of negative consequences 2 months later. For these outcomes, effect sizes associated with LezParlay treatment arms at the 2-month follow-up were consistent with or exceeded the short-term effects associated with treatment arms of traditional, remotely delivered PNF alcohol interventions in other populations -55. ThusIn addition to being a feasible and effective means of delivering PNF to this population, LBQ drinkers also found the LezParlay competition to be both highly acceptable and psychologically beneficial. Notably, the detailed results  were the most liked aspect of LezParlay, and ratings were not significantly associated with study condition or baseline alcohol consumption. Thus, those receiving fewer and more health-related results as a function of condition and those entering the study as lighter and heavier drinkers similarly enjoyed receiving the PNF delivered. These findings suggest that future versions of the competition might also correct additional types of alcohol and coping-related norms or expand the topics on which PNF is delivered to other areas of physical and mental health without detracting from acceptability or engagement. Most participants also reported that they psychologically benefited from taking part in the competition, and descriptions of benefits reflected learning and social comparison, community connection and identity strength, stigma reduction, enhanced mood or outlook, and entertainment. Many of these benefits map onto LezParlay’s social media–inspired web-based community features, the constellation of game mechanics, and the broad challenging of negative LBQ stereotypes and, importantly, extend far beyond the psychological benefits associated with traditional PNF alcohol interventions. Finally, participants submitted several actionable ideas for ways in which the LezParlay app, user experience, and competition format could be improved. These insights will inform the next version of LezParlay.To date, alcohol interventions developed for sexual minorities have tended to be clinical, intensive, and focused on affirming sexual identities, aiding individuals in understanding sexual minority stress processes, and providing resources to help individuals cope with stigma more adaptively ,58,59. AThe present findings also bring clarity to confusion in the substance use literature around the appropriateness and utility of social norms interventions for health disparity populations . For insThis study’s feasibility findings also provide an innovative answer to challenges related to reaching and engaging stigmatized minority populations with PNF in the real world. LezParlay delivered the core components of a PNF intervention within a fun, culturally tailored digital competition designed to challenge negative stereotypes about the target population. This gamified, incognito intervention approach was found to be highly engaging, acceptable, and psychologically beneficial among alcohol-consuming LBQ women and meaningfully reduced their alcohol-related risks. Although more research is needed, the stereotype challenge concept, along with the injection of established game mechanics and cultural themes, may have similar utility in reaching other high-risk stigmatized minority groups with PNF on drinking and other health risk behaviors. Finally, looking past PNF, findings from this study also suggest that challenging negative identity-related stereotypes and including web-based community features may also prove fruitful in minority, stress-informed digital health and mental health programs targeting internalized stigma, loneliness, and isolation ,63,64.As the initial step in a new direction for alcohol intervention development, the key limitations associated with this study include the relatively short duration of the follow-up period, organic assessment of baseline and follow-up alcohol outcomes within rounds of the competition at T1 and T2, and assessment of acceptability and psychological benefits only among LBQ drinkers involved in the RCT. Thus, future evaluation efforts should follow participants for a longer duration (6-24 months), incorporate survey-based baseline and follow-up assessments, and examine the acceptability and psychological benefits among nondrinkers and other LBQ players not involved in the efficacy portion of the trial. An additional limitation to be remedied in future research is this trial’s lack of an assessment-only control condition. Although randomizing participants to receive PNF on either treatment or control topics, as was done in this study, reflects the gold standard trial design in the PNF intervention literature, it may not be optimal when PNF is delivered within a culturally tailored digital competition focused on challenging negative group stereotypes. That is, participants in all 3 PNF conditions described unanticipated, far-reaching psychological benefits associated with broader participation in the competition, including stigma reduction, community connection, and identity strength. As these factors are theorized to diminish the degree to which sexual minority stress negatively impacts health risk behavior ,66, it itrending health-related norms [Although this efficacious initial version of LezParlay was a standalone intervention focused exclusively on correcting descriptive drinking and coping norms, exciting directions for future research also lie in the prospect of incorporating additional components to further reduce alcohol-related risks and increase wellness more broadly. For example, future research may seek to evaluate the utility of including a judgment-based reflective injunctive alcohol normative feedback component that builds on promising pilot findings among college students . The comed norms ,68 focused norms . Thus, aThe results of this hybrid trial provide initial support for the feasibility and efficacy of LezParlay as a culturally tailored, gamified, PNF alcohol intervention for LBQ women, thereby narrowing costly disparities in alcohol intervention research and practice. The reductions in alcohol use and negative consequences associated with PNF on drinking and coping delivered within LezParlay demonstrate the utility of PNF as an alcohol intervention strategy for a stigmatized minority health disparity population. These findings should behoove substance use researchers developing interventions for sexual minorities to consider such sexual identity–specific peer norms as potential intervention targets. Furthermore, to overcome engagement challenges associated with delivering PNF to non–treatment-seeking members of stigmatized minority groups and broaden the psychological benefits associated with this strategy, the findings underscore the value of packaging PNF within a broader culturally tailored competition designed to challenge negative group stereotypes.


Cancer is the second leading cause of death worldwide, with 10.0 million cancer deaths in 2020. Despite advances in targeted therapies, some pharmacological drawbacks associated with anticancer chemo and immunotherapeutic agents include high toxicities, low bioavailability, and drug resistance. In recent years, extracellular vesicles emerged as a new promising platform for drug delivery, with the advantage of their inherent biocompatibility and specific targeting compared to artificial nanocarriers, such as liposomes. Particularly, mesenchymal stem/stromal cells were proposed as a source of extracellular vesicles for cancer therapy because of their intrinsic properties: high in vitro self-renewal and proliferation, regenerative and immunomodulatory capacities, and secretion of extracellular vesicles that mediate most of their paracrine functions. Moreover, extracellular vesicles are static and safer in comparison with mesenchymal stem/stromal cells, which can undergo genetic/epigenetic or phenotypic changes after their administration to patients. In this review, we summarize currently reported information regarding mesenchymal stem/stromal cell-derived extracellular vesicles, their proper isolation and purification techniques - from either naive or engineered mesenchymal stem/stromal cells - for their application in cancer therapy, as well as available downstream modification methods to improve their therapeutic properties. Additionally, we discuss the challenges associated with extracellular vesicles for cancer therapy, and we review some preclinical and clinical data available in the literature. Cancer is the second leading cause of death worldwide after cardiovascular diseases  stroma, that contribute to the maintenance and regeneration of different connective tissues  . These cng units , desirabin vitro . Becausein vitro . Apart fin vitro . While Bin vitro . Regardiin vitro . Both huin vitro . Particuin vitro .in vitro and in vivo. These cells secrete a variety of soluble factors and chemokines that mediate immunosuppression by inhibiting B and T cells, monocyte maturation, as well as the generation of regulatory T cells and M2 macrophages polarization  . For insfication . Developfication .in vitro and in vivo in a cell number-dependent manner by inducing cell cycle arrest and apoptotic death in different cancer cell lines  significantly promoted in vitro proliferation and migration of breast cancer cells and in vivo tumor progression compared with their ‘young’ counterparts (UC-MSCs at passage 5). They also identified IL-6 as the main mediator of these pro-tumoral effects , gap-junctions, or mitochondrial DNA transfer through EVs . In addiactivity . FurtherDespite the fact that MSCs have been used in many clinical trials to treat several pathologies, the inoculation of viable MSCs into patients entails some hindrances. These include limited passaging before entering a senescent state –in particular with BM-MSCs -, cellular heterogeneity, the alteration of their differentiation potential under hypoxic conditions, the occurrence of epigenetic changes during culturing - in genes that regulate self-renewal -, excessive immunosuppression, and risk of lung embolism . Those aAccording to the International Society of Extracellular Vesicles, EVs are “nanosized lipid bilayer encapsulated membranes carrying proteins, lipids, nucleic acids and sugars that are shed by the majority of the cells into the extracellular milieu to mediate intercellular communication, by transferring molecules from parental/donor cells to target cells” . AdditioFinally, apoptotic bodies (ABs) are the largest membrane-bound extracellular vesicles –of 1–5 μm in diameter - generated during apoptotic cells disassemble . ABs plain vivo . They also require making batch-to-batch comparisons through specific biochemical, biophysical, and functional/potency assays. In this way, the early characterization of the manufacturing process is crucial since it enables the design of untimely standard operation procedures and the identification of potential risks and bottlenecks in advance, guaranteeing consistency and reproducibility . EVs manin vitro and in vivo testing are required. Despite several methods are available in the literature for viral inactivation –including solvents, detergents, irradiation, and nanofiltration-, their utilization may alter EVs structure and content . This clinical study is currently evaluating the best dose and associated side effects of MSC-derived exosomes loaded with KrasG12D siRNA (iExosomes) during the treatment of participants with metastatic pancreatic cancer bearing the KrasG12D mutation. Although gemcitabine has been the standard of care for this particular type of cancer, there is a poor response to this drug, leading to reduced overall survival  in a rat lung preservation model had higher anti-inflammatory effects when compared with the administration of HUCPVCs   . These rin vitro culturing, researchers may tread carefully when using MSCs for cancer cell therapy. Consequently, the utilization of MSC-derived EVs –either naïve or modified to improve their delivery and targeting properties– as cell-free DDSs allowed to overcome some of the drawbacks associated with cell therapy since EVs are static and do not reproduce or represent a mutational risk when administered to patients. Moreover, because of their inherent biological complexity, EVs display better tropism and biocompatibility when compared with artificial nanocarriers. However, there are still some limitations associated with EVs as DDSs. To begin with, as any biological product, EV formulations must fulfill the requirements of regulatory agencies in terms of purity, safety, efficacy, and batch-to-batch homogeneity. The exhaustively controlled manufacturing processes and quality control protocols needed to accomplish GMP and regulatory standards also enormously increase the cost of EV production. Due to EVs biological complexity, it may be difficult to assess if the lipid bilayer, their content, or both are responsible for their therapeutic effect. Furthermore, the procedures employed for EVs engineering require additional purification steps to eliminate potential reagent contamination, and most of those procedures tend to increase even more the final product cost and may result in low yields as well. Additionally, it has to be kept in mind that, when using MSC-derived EVs, researchers need to keep investigating their not yet fully understood effects on tumor progression. Nevertheless, there has been an exponential development of new approaches to overcome those methodical and cost-associated limitations. For instance, the emergence of hybrid vesicles –by the fusion of sEVs and liposomes– and exosome-mimics brought together “the best of both worlds”, shedding some light over the new emergent paradigm of biological nanovesicles as DDSs. In the last 4 years, many research groups have published pre-clinical data regarding the potential applications of engineered sEVs for cancer therapy, with some promising results. Since these reports are heterogeneous in terms of the engineering methods used, source of the parental MSCs, and the tumor models employed, new efforts are required to design and standardize protocols that will undoubtedly facilitate EVs translation to the clinic for theragnostic applications.Anti-cancer drug development is a challenging field because not only tumors can develop both intrinsic and extrinsic mechanisms of drug resistance, but also antineoplastic drugs may be associated with low bioavailability and off-target effects. Although MSC-based therapy has been investigated for many years for its application for cancer treatment due to their biological properties –mainly their low immunogenicity and tumor tropism - many groups reported contradictory results regarding the pro and anti-tumoral effects of MSCs. Although these discrepancies among studies have been attributed to the differences between tissue sources and donors and the lack of standardized protocols for MSCs isolation and


Background: Indigenous South Australians carry a disproportionate burden of dental diseases, with approximately 80 percent of Indigenous adults having both periodontal disease and dental caries. The chronic inflammatory nature of many dental conditions means there are widespread systemic impacts, particularly on type 2 diabetes, chronic kidney disease and cardiovascular disease. Evidence suggests there are barriers experienced by Indigenous South Australians in accessing timely and culturally safe dental care. This study aims to: (1) elicit the views of Indigenous South Australians regarding their perspectives of what comprises culturally safe dental care; (2) provide such dental care and; (3) assess any changes in both oral and general health using point-of-care testing following receipt of timely, comprehensive and culturally safe dental care. Methods/Design: This mixed-methods study will involve qualitative interviews and an intervention without randomisation. The qualitative component will comprise seeking perspectives of Indigenous South Australians regarding what culturally safe dental care means for them. For the intervention component, participants will take part in oral epidemiological examinations at baseline and 12-month follow-up , which will include collection of saliva, plaque and calculus, as well as completion of a self-report questionnaire. The primary outcome measures—changes in type 2 diabetes (HbA1c), cardiovascular disease (CRP) and chronic kidney disease (ACR)—will be obtained by blood/urine spot from a finger prick/urine collection at baseline and 12-month follow-up via point-of-care testing. Results: Participant recruitment will commence in July 2022. The first results are expected to be submitted for publication one year after recruitment begins. Discussion: The project will have a number of important outcomes, including increased understanding of what culturally safe dental care means for Indigenous South Australians, the delivery of such care, and empirical evidence of how culturally safe dental care leads to better prognosis for chronic diseases linked with poor oral health. This will be important for health services planning, especially in the Aboriginal Community Controlled Health Organisation sector, where the management of dental diseases in a culturally safe manner for better chronic disease outcomes is currently insufficiently understood, planned and budgeted for. Oral health is an important indicator of overall health and wellbeing . The twoThe mouth contains over 300 species of bacteria, with an entry point to the digestive, respiratory and circulatory systems . EvidencThere are two main mechanisms by which poor oral health, specifically periodontal disease, contributes to systemic disease. The first is a direct mechanism; as chronic periodontitis progresses, the epithelium lining periodontal pockets becomes ulcerated, providing a direct entry point for periodontal bacteria into the systemic circulation. The circulating bacteria may directly affect certain organs, for example, periodontal bacteria have been detected in thrombi from patients with acute myocardial infarction suggesting a role in the pathological changes that occur in atheromatous plaques . PeriodoIn a field of research that has over 30 years of clinical trials, there is conclusive evidence that comprehensive dental care improves systemic diseases, specifically through scaling and root planing of the teeth and gums where periodontal disease is evident. This serves to reduce the bacterial load in the mouth, reduce the inflammatory burden contributed by the oral cavity to the systemic system, and provide a smooth tooth surface that is difficult for bacteria to adhere to in future . In a reMany Indigenous Australians do not seek dental care because of a lack of cultural safety in the dental setting ,21. TherIf dental services provided to Indigenous Australians are not culturally safe, Indigenous Australians will not present for dental care. If Indigenous Australians do not present for dental care, the impacts of poor oral health may manifest substantially on the 57 systemic conditions identified as being associated with periodontal disease. Being able to provide evidence of the benefits of improved oral health among Indigenous Australians for improved systemic health is essential before there can be any translation to health policy. This includes, in the context of Indigenous Australians, having dental included in chronic disease health management plans, and regular engagement of health staff managing Indigenous patient chronic diseases with dental staff.One of the main difficulties in studying links between periodontitis and systemic disease is that they share some risk factors. Any changes in systemic disease biomarkers will be influenced by a multitude of factors, not just treatment of dental disease. These include medical management, comorbidities, new medications, adherence to medication, health literacy and education. Traditionally, randomised controlled trials (RCTs) have been the only study design to identify cause and effect relationships that account for such confounders. For research questions (such as those from this project) in which conducting RCTs are unethical or impractical, causal inference methods can be used to estimate causal effects from observational data . To estin = 749), and again at 24-month follow-up (n = 741) [Our team has 18+ years working in partnership with Indigenous communities in Australia providing dental interventions, including the collection and assessment of systemic disease biomarkers. For example, Jamieson was the dentist involved in the Aboriginal Birth Cohort study in the Northern Territory, in which blood and urine was collected from children from the age of 4 years . Kapellan = 741) . Our tean = 741) ,33. ThisPoint-of-care testing is a quality-assured pathology service using analytical devices provided near to the patient rather than in the traditional environment of a clinical laboratory . The objOur study aims are as follows:Aim 1: To determine barriers to, and facilitators of, culturally safe dental care among Indigenous South Australians. Hypothesis: Barriers to culturally safe dental care will include a range of macro  and micro  factors.Aim 2: To work with the Indigenous South Australian community and dental service providers to provide culturally safe dental care.Hypothesis 1.Culturally safe dental care can be provided with sufficient training, resources, goodwill and commitment from the broader dental community.Aim 3: To ascertain changes in both clinical and self-reported oral health and general health following completion of dental care, using point-of-care testing for the general health biomarkers.Hypothesis 2.Receipt of culturally safe dental care will contribute to improvements in dental health, clinical biomarkers of systemic disease as ascertained through point-of-care testing, and self-reported general and oral health.This mixed-methods study will follow recommendations of Creswell  and willWe will recruit 1000 Indigenous South Australian children and 1000 Indigenous South Australian adults, with a focus on our key partner sites of Adelaide, Ceduna, Coober Pedy, Whyalla and Port Lincoln. Census data indicates approximately 22,000 Aboriginal adults and children reside in these areas. The investigators have an 18-year relationship with key Indigenous stakeholder groups in these locations. Recruitment strategies will be based on those successfully implemented in our past Indigenous dental projects. Participants will primarily be sourced from the participating Aboriginal Community Controlled Health Organisations (ACCHOs) in the first instance. Information about the study will be provided to all ACCHO staff , through a presentation and one-on-one conversations. ACCHO staff who work closely with Indigenous clients  will, in turn, describe the study to potential participants and direct the study’s Indigenous research officers to facilitate recruitment if participants are willing. We will employ a snowball recruitment technique also; whereby study participants can contact their own family and friends to become involved in the study if interested. Retention strategies will involve: (1) employing staff who are committed to following up participants despite challenges in doing so; (2) ensuring participants are contacted on a regular basis to check accuracy of contact details; (3) maintaining relationships with appropriate stake holders; (4) ascertaining contact details of three key personnel who may know the whereabouts of participants should the study team be unable to contact them; (5) sending birthday and Christmas cards to participants; and (6) facilitating one-on-one relationships between study staff and participants, with study staff ideally seeing each of their participants for each phase of the research.Participants will be aged 6 months and above, identify as being Aboriginal or Torres Strait Islander and planning to live in South Australia for the next 3 years. Participants, who are not enrolled during the original recruitment period, will not be eligible to participate in the 12-month follow-up.Ethical approval has been obtained by the Aboriginal Health Council of South Australia’s Human Research Ethics Committee (04-22-990) and the University of Adelaide Human Research Ethics Committee.Primary outcome: For purposes of the intervention component of the study, the primary outcome will be clinical biomarker changes of three systemic conditions assessed through point-of-care testing; type 2 diabetes (HbA1c), cardiovascular disease  and chronic kidney disease .Secondary outcomes: Secondary outcomes will include dental caries experience, periodontal status, oral health-related quality of life, general health-related quality of life and other systemic disease biomarkers; IL-6, GFR, HDL and LDL cholesterol and triglycerides.Covariates: Covariates will comprise socio-demographic factors (including education), oral health and general health behaviours , health literacy, medical management, medications, adherence to medication and comorbidities, especially obesity.Qualitative, self-report and clinical information will be gathered in this study.Qualitative: At baseline, participants, or carers of child participants, will be asked to take part in one-on-one interviews with study stuff to ascertain views on what culturally safe dental care means. At 12-month follow-up, after receipt of dental care, participants will take part in a follow-up interview to capture participant views on the dental care journey. Interviews will follow a standard prompt guide, will be audio-recorded and professionally transcribed.Self-report: Self-report information pertaining to socio-demographic, oral health and general health factors will be gathered at baseline and 12-month follow-up. Socio-demographic factors will include age, sex, education level, employment, number of people who stayed in house the previous night and car ownership. Oral health factors will include self-rated oral health, oral health-related behaviours and quality of life. General health factors will include behaviours such as smoking and alcohol consumption and general health-related quality of life.Clinical: At baseline, each participant will undergo an oral epidemiological examination and provide saliva, calculus and plaque samples. Adults will also provide blood drops (obtained via finger prick) and urine for point-of-care testing for HbA1c, CRP and ACR. This will be repeated at 12-month follow-up, after receipt of the culturally safe dental intervention.Oral epidemiological examination: This will include tooth presence, dental caries experience, periodontal destruction, gingivitis and calculus, plaque, oral mucosal lesions and dental trauma.Plaque, calculus and saliva samples: Saliva samples will be collected using commercially available kits, which will involve participants: (a) not eating or drinking for 30 min prior to collection; (b) removing the funnel lid on the container; (c) spitting until 2 mL reaches the fill line (takes 2 min); (d) closing the lid and unscrewing the lid from the funnel and; (e) placing the small cap on the tube and shaking the tube for 5 s. Dental personnel collecting oral epidemiological information will collect supragingival plaque and calculus samples using a sterile Gracey curette. The plaque and calculus will be collected from the buccal surface of two incisors and the mesio-buccal surface of the maxillary first and second molars, and placed into individual Eppendorf tubes. Saliva, calculus and plaque samples will be transported to a University of Adelaide laboratory for analysis.Systemic disease biomarkers (adults only): A blood sample will be collected via a capillary finger stick with disposable lancet. Urine will be collected by a standard urine pot with sealed lid . This will occur at baseline and 12-month follow-up. Three to five blood/urine spots will be analysed according to the directions provided for the point-of-care testing system Afinion™ for the analysis of primary outcomes HbA1c, CRP and ACR, and secondary outcomes IL-6, GFR, HDL and LDL cholesterol and trigylcerides.Given our past experience of large-scale dental initiatives involving Indigenous persons in South Australia , we antiTo ensure culturally safe and respectful practice, health practitioners must acknowledge colonisation and systemic racism, social, cultural, behavioural and economic factors which impact individual and community health’. Key points, which will be utilised in the current study, include genuine engagement of Indigenous Australians in oral health care programs in environments that are culturally acceptable and sensitive. The investigators, through leadership of the study’s Senior Indigenous Research Officer (Hedges), will ensure all study activities are conducted in culturally safe ways. All non-Indigenous staff/students will undertake cultural safety training. Culturally safe practise will be reinforced through monthly debriefing sessions, organised by the study’s Senior Indigenous Research Officer to ensure that the many fears of Indigenous clients in accessing dental care  are acknowledged and mitigated in personal and tailored ways. Through all aspects of data collection and dental service provision, Indigenous participants need to feel safe in any encounter with the dental sector; from the receptionist through to the specialist.In 2020, the Australian Health Practitioner Regulation Agency, with whom all dental personnel in Australia need to be registered, stated that ‘The clinical aspects of the oral health intervention will be based on the technique described by Tonetti and colleagues , and occInterpreting the results of both quantitative and qualitative methodologies will be conducted in accordance with Creswell’s recommendations for mixed-methods research . In brieAim 1: Barriers/facilitators culturally safe dental care. A two-stage approach to coding will be used in the thematic analysis of transcripts from the interviews. A primary analytical framework (the first stage) will be structured using the interview guide to create a coding scheme [g scheme , which wAim 2: Provision of culturally safe dental care. The assessment of provision of culturally safe dental care will be through the perspective of participants who received the intervention; both children and adults. This will be garnered through qualitative interviews at the follow-up assessments, with the same analytical frameworks utilised as described for the analysis of Aim 1.Aim 3: Changes in clinical biomarkers. Analysis of covariance will be performed to determine differences in the primary, secondary and other outcomes between baseline and 12-month follow-up. Causal inference and sensitivity analyses will be used to emulate a target trial approach [approach . This inParticipant recruitment for this study will commence July 2022. We anticipate the first results to be submitted for publication one year following initial recruitment.Culturally safe dental interventions for Indigenous Australians to improve systemic disease biomarkers are essential to inform policy translation that might result in dental care provision as a part of chronic disease management in the Aboriginal Community Controlled Health Organisation setting across Australia. Point-of-care testing is an important element of intervention research involving the collection of biodata because it alleviates involvement of third-party laboratory services, means no storage is required, provides participants with immediate results and requires much smaller volumes of blood and urine. Understanding Indigenous Australian perspectives of what culturally safe dental services are will provide valuable knowledge for the creation of culturally safe training programs both in dental teaching institutions and in continuing professional development modules for dental professionals. The project provides a key example of how carefully calibrated, data-driven disease models can integrate with Aboriginal community views and expectations to estimate disease burden, deliver culturally safe dental care and guide policy decisions for more equitable resource distribution that includes dental as part of chronic disease management for Indigenous Australians.The strengths of the study include it being the first to obtain and link all the information around oral health and general health through a mixed-methods, culturally safe intervention approach in partnership with the Indigenous South Australian community. The focus on engagement, enabling Indigenous community and individual preferences to play a large role in where and how data collection will take place, and how findings will be disseminated builds upon a platform of reciprocal and respectful research processes across almost 20 years . The finThe study limitations include the sample frame for dental disease assessment and provision of culturally safe dental care being pragmatic, that is, utilising convenience sampling methodology, which maybe. there is a risk of sampling bias. While the efforts required to obtain a representative sample are recognised as being both expensive and time-consuming . We remaEngaging dental clinics at the beginning of the project ensures they are familiar with the study team, the study’s aims and develops close ties/relationships to support the client. Asking questions of the study team eliminates unnecessary concern by the client, e.g., financial queries.The project will have a number of outcomes, which is important for health services planning, and for Aboriginal health worker and patient education.