The aims of this study were to investigate whether dental and dental hygienestudents’ career plans postgraduation were affected by the coronavirusdisease 2019 (COVID-19) pandemic and to examine wellness and readiness forclinical practice among students who reported a change in career plans.An anonymous online REDCap survey was developed and emailed to 436 dental anddental hygiene students at a US dental school. The survey consisted of 81questions that covered demographics, career plans postgraduation, andreadiness and wellness measures. An open-ended question assessing howstudents’ career plans have changed during the pandemic was alsoincluded.P = 0.003) and anxiety  scores and lower mean resilience  scores than those who reported no change to their career plans.Concerns were raised regarding the limited employment opportunities,long-term stability of the dental profession, and the interruptions toclinical education and licensure examinations consequent to thepandemic.A total of 252 students completed the survey, of whom 11.5% reported thattheir plans for future dental practice have changed since the COVID-19outbreak. Students who reported a change to their career plans hadsignificantly higher mean perceived stress (20.1 vs. 16.3;A comprehensive effort inclusive of adeptly designed clinical and curriculumexperiences paired with wellness interventions and support tailored tostudents is needed. These measures need to support trainees across varyingyears in training and resilience levels to be effective for dental anddental hygiene students as they approach their future career intentions inthe dental profession. Additional longitudinal research is needed to assessif change in career intentions during the COVID-19 pandemic corresponds withactual change postpandemic and affects the dental profession.This study explores the potential short-term change in career intentions ofdental hygiene and dental students during the COVID-19 pandemic. Findingscan inform workforce planning as well as interventions developed andimplemented by academic dental institutions to support student wellnessduring unexpected and prolonged emergency situations. The coronavirus disease 2019 (COVID-19) pandemic has greatly affected health caredelivery, particularly dental care . DropletThis unprecedented pandemic has disrupted dental education and training. At theheight of the pandemic, academic dental institutions responded by moving classroominstruction online and temporarily closing clinics .A surveAlthough the impact of the pandemic on dental education and training is indisputable,its impact on students’ career trajectories is not well understood. Prior researchon career motivations has found that dental hygiene students pursue their professiondue to a desire to have a career in the health care field, serve the community, andreceive good salaries . SimilarTo date, the ramifications of the COVID-19 pandemic on students’ career intentionsare not clear. Analyzing changes in students’ career plans is important inunderstanding the long-term effects of prolonged and unanticipated public healthcrises on the dental workforce. To this end, the aims of this study were toinvestigate whether dental and dental hygiene students’ career plans postgraduationwere affected by the COVID-19 pandemic and to examine wellness and readiness forclinical practice among students who reported a change in career plans.An anonymous online REDCap survey  was deveThe survey consisted of 81 questions that covered a wide range of topics, includingdemographics, anticipated educational debt, career plans postgraduation, andreadiness to enter clinical practice or residency. The survey also incorporatedpreviously validated scales with acceptable internal reliability to assess studentwellness. These scales include the Perceived Stress Scale (PSS-10) ,GeneralP < 0.05 was deemedstatistically significant.This study focused on a subset sample from the broader survey consisting of studentswho responded yes to the question, “Since the COVID-19 outbreak, has your plans forfuture dental practice changed?” Descriptive statistics for demographics , anticipatededucational debt, readiness to enter clinical practice/residency, and wellnessscores  by change in careerplan (yes or no) were calculated using SAS 9.4 (SAS Institute). Differences infrequencies of responses to demographic and readiness measures were analyzed withFisher’s exact test. Differences in mean wellness scores between survey participantswho reported a change to their career plans and those who did not were assessedusing an analysis of variance (ANOVA). Survey respondents who answered yes to a change in their future career plans sincethe COVID-19 outbreak provided responses to an open-ended question of “how theirplans have changed.” Qualitative assessment of this open-ended question allowed theauthors to expand beyond the close-ended question and explore the range of students’responses to career plans change during the COVID-19 outbreak. Responses to theopen-ended question were assessed using inductive thematic analysis conducted by 2members of the research team , with training in qualitative methods .Analysin = 252),a much higher proportion of fourth-year dental hygiene students (44.4%), followed bythird- and fourth-year dental students , reported achange in their postgraduation career plans. Slightly less females than males  in the overall survey sample reported a change to theirfuture career plans.Of the 252 students who completed the online REDCap survey, 29 (11.5%) reported thattheir plans for future dental practice have changed since the COVID-19 outbreak. More thP = 0.004), stress , and resilience scores . There wasno significant difference between groups with respect to social support , coping ,or self-reported readiness to enter clinical practice or residency(P = 0.4).Comparison of readiness to enter the clinical practice/residency and wellnessmeasures between students who reported a change and those who did not report achange in their future career plans due to the COVID-19 outbreak revealed noteworthydifferences. For instance, the 2 groups differed significantly on anxiety Among final-year dental and dental hygiene students, 40% reported that they havenot been able to secure their desired postgraduation employment. Some studentsreported difficulties finding any employment during the COVID-19 pandemic.Others were unable to secure a position in a location they desired or statedthat they anticipate working part-time rather than full-time upon graduation.The main reported barrier to obtaining their desired employment during theCOVID-19 pandemic was the limited opportunity to communicate with practiceowners due to closures resulting from the stay-at-home orders. Half of thefourth-year dental hygiene students also identified interruptions to licensureexamination as a major barrier to postgraduation employment. Indeed, afourth-year dental hygiene student indicated a lack of willingness to pursue aninitial career plan with the Indian Health Service (IHS) due to delays inobtaining licensure, as noted here:Anxiety about [my] ability to accomplish certain procedures duringlimited time in dental school that may limit my ability to be aqualified candidate while applying to residencies. The COVID-19 pandemic also influenced third-year and nonclinical-year dentalstudents’ perceptions of the future job market and their readiness to enter it.Several students reported feeling unsure of the imminent job environment; as onestudent stated, “We do not know how long this outbreak will last.” Students’perception of a forthcoming dismal job market stemmed from concerns regardingthe long-term financial strain of COVID-19 on dental schools and/or dentaloffices. Specifically, students reported uncertainty on whether or not dentistswill be hiring associates in their private practice consequent to the reducedpatient volumes attributed to the COVID-19 pandemic. Third-year dental studentsalso reported feeling less confident in applying to residency programs orentering private practice directly given the extended interruption to theirclinical education. For 1 third-year dental student, the academic disruption tohis clinical education left him feeling anxious about his ability to accomplishcertain clinical procedures prior to applying to residency programs, as noted here:Given the heightened sense of uncertainty regarding the impact of the ongoingCOVID-19 pandemic on the dental job market, several students reported they willpursue alternative career plans postgraduation. Among dental hygiene students, 1student reported they will enroll in a master’s of public health program insteadof joining the dental workforce as initially planned. Similarly, the most commonalternative career plan mentioned by dental students across all years oftraining was enrolling in a residency program. However, students pursuing thisoption reported facing additional barriers such as having to take on additionalstudent debt as well as not being able to travel and visit such programs inperson before applying due to travel restrictions brought on by thepandemic.I am very concerned that dental schools and/or dental offices will not behiring due to the financial strain of COVID-19. I may not be able tofind employment and may need to find a residency program to continue topractice dentistry, which will require me to take on more student loandebt. Similarly, first-year dental students also reported change to their future careerplans due to the COVID-19 pandemic. One student who initially planned tospecialize in oral and maxillofacial surgery (OMFS) reported she will no longerpursue that specialty after learning of a COVID-19–related death of an OMFSresident. Instead, she is now considering completing 1 or 2 y of residency orjoining the dental workforce sooner.Initially I planned on specializing but since the COVID-19 outbreak andlearning about the death of the OMFS resident in Detroit, I much ratherdo one or two years of GPR or AEGD and join the workforce sooner.I thought Dentists had some of the best job security and didn’t foreseeany reason dentists would have to close their practices like this for anextended period of time. Not knowing what the future “normal” will looklike when the COVID-19 outbreak settles down makes me slightly anxiousabout the future and has made me question whether my plan for the futureis as secure as I thought it was or if I need to do more. For several students, the COVID-19 pandemic influenced their perception of theoverall stability of the dental profession. The closures of dental practices dueto the outbreak left some students questioning the long-term job security oftheir chosen profession. Students shared statements such as “I thought dentistshad some of the best job security” and “I don’t know if this is what makes mehappy anymore—no security, lack of communication.” Some students stressedneeding to be prepared in case another outbreak occurs while others were unsureif they should be doing more to prepare themselves, as noted here:The average debt amount we will be graduating in 2023 will be $500K at 7%interest rate, which is $35,000 of accrued annual interest alone. Payingthis loan aggressively only makes sense if your income is $250K+ aftertaxes, but realistically it will take over a decade to do so, and makingthis move severely limits loan borrowing power when looking to purchasea private practice. 20 year IDR plans like REPAYE are much betteroptions. The biggest concern is patient volume, increased cost of care,reduced hiring for associate dentists, permanent teledentistry shift, health concerns for my patients,staff, and my family. Other students expressed concern over the potential long-term impact of thepandemic on the dental profession and how it is practiced. One student wasparticularly concerned that the reduced patient volume would negatively affecthis ability to pay off dental school loans and purchase his own private practicein the future. Furthermore, this student also expressed concern over thepossible shift toward teledentistry as well as ongoing health risks forpatients, staff, and family, as noted here:The purpose of this study was to investigate whether the postgraduation career plansof dental and dental hygiene students at a US dental school were affected by theCOVID-19 pandemic. To our knowledge, this is the first study to examine theshort-term impact of this pandemic on dental and dental hygiene students’ careerintentions. Furthermore, findings from this survey, which was administered fromApril 28 to May 17, 2020, provide a baseline understanding of COVID-19–relatedchanges in career intentions within this population to allow for future assessmentas the pandemic continues to evolve.Over 10% (11.5%) of survey respondents reported a change to their future career plansdue to the COVID-19 pandemic, with the highest proportion of change reported amongfourth-year dental hygiene students and clinical-year dental students (D3 and D4).These students expressed COVID-19–related employment concerns stemming frominterruptions to licensure examinations and their inability to communicate withpractice owners during practice closures. This is not surprising to find given thatat the time of the survey, only 3% of dental practices in the United States wereopen with business as usual . ThisfiNonetheless, our findings suggest that dental and dental hygiene students whoreported a change in career plans actually experienced a career shock, defined asdisruptive and extraordinary events, such as the COVID-19 pandemic, that trigger adeliberate thought process concerning one’s career . We founFindings from this study also revealed that racially minoritized students were morelikely than White students to report a change in their career plans due to theCOVID-19 pandemic. This finding may be reflective of the underlying inequities ineducation and the broader sociopolitical context that minoritized studentsexperience, including the pervasive prominence of racism compounded with thedisproportionate burden of the pandemic on minoritized communities . ApotenExamination of wellness measures showed that students who reported a change in theircareer plans due to the COVID-19 pandemic had significantly higher anxiety andperceived stress scores compared to those who did not report a change in futurecareer plans. Similarly, a study conducted with licensed US dentists at the heightof the pandemic found that 19.5% of participants reported symptoms of anxiety,underscoring the psychosocial impact of the pandemic across students and providersin the dental field . StudentWhile current dental school curriculums leave little room for additional contacthours, the overwhelming association of resilience as a protective factor for mentalhealth disorders and stress, as well as documented evidence of higher trendingburnout in clinical practitioners , lends iAs with all studies, there are limitations to this work. First, findingsrepresent students’ self-reported intended change in career plan due to theCOVID-19 pandemic and not necessarily the actual future career path. Careerplans might continue to change, positively and negatively, as the COVID-19pandemic continues to evolve . Second,This study examined the short-term impact of the COVID-19 pandemic on dental hygieneand dental students’ career intentions. Findings demonstrate that students whoreported an intent to change their career plans had significantly higher perceivedstress and anxiety scores and lower resilience scores than students who reported nochange to their career plans. Racially minoritized students were more likely toreport a change in career plans than White students were. Students who reported achange in their career plans were concerned about limited employment opportunities,the long-term stability of the dental profession, and interruptions to clinicaleducation and licensure examinations consequent from the pandemic. It is importantthat dental training programs have the financial and institutional support toprovide safe and supportive in-person, virtual, and clinical training environmentswith the communication structures to support students and build a confident andresilient dental workforce.D.T. García, contributed to conception, design, data acquisition, analysis, andinterpretation, drafted and critically revised the manuscript; A.A. Akinkugbe,contributed to conception, design, data acquisition, analysis, and interpretation,critically revised the manuscript; M. Mosavel, contributed to conception, design,data analysis, and interpretation, critically revised the manuscript; C.S. Smith,T.H. Brickhouse, contributed to conception and design, critically revised themanuscript. All authors gave final approval and agree to be accountable for allaspects of the work.


Acute aortic dissection (AAD) is a life-threatening condition which can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. Mortality of surgical treatment in high-risk or elderly patients with Type A AAD (TAAAD) still remains high, and treatment for such patients remains controversial. We report a successful treatment of TAAAD with a communicating false lumen in a 60-year-old man with acute hemi-cerebral malperfusion..The ascending aorta was wrapped with stepwise external wrapping (SEW) procedure, and subsequent thoracic endovascular aortic repair (TEVAR) was successfully performed. The patient was discharged in good physical condition without any complicationsHybrid therapy with SEW and TEVAR with TAAAD associated with major cerebral malperfusion should be considered, especially in patients for whom open surgery is extremely risky. We herein report a successful less-invasive hybrid therapy of type A acute aortic dissection (TAAAD) in a 60-year-old man with acute hemi-cerebral malperfusion.The patient was a 60-year-old man with a medical history of untreated severe sleep apnea syndrome, hypertension, and paroxysmal atrial fibrillation without any medication because of low compliance. At early morning, he had sudden back pain and was unresponsive. He was found in his car, and emergently transported to a tertiary medical facility. He demonstrated left hemiplegia, conjugate deviation of the eyes, and convulsions. He was intubated and computed tomography (CT) showed absence of perfusion to right whole cerebral artery without any irreversible brain damage and TAAAD with a 20 mm of intimal tear in the descending aorta, and obvious cardiac tamponade Fig. a-d. The We performed emergency surgery. Initially, median sternotomy was performed, and cardiopulmonary bypass was established through femoral arterial cannulation and single two-stage venous cannulation via right atrial appendage. Intraoperative transesophageal echocardiography demonstrated mild aortic regurgitation. We then proceeded to treat the patient using the new surgical approach devised by us for high-risk patients, reported previously  , 2. The The length of hospitalization was 14 days. No neurological complications or minor complications were encountered. Postoperative CT showed that proper positioning of the stent graft without any endoleak, good brain perfusion  at the level of the descending aorta also showed a change in the balance of the flow between the true lumen and false lumen.In selected extremely high-risk patients, like in this case, which would generally have been considered to be inoperable, hybrid therapy with SEW and TEVAR may be a viable alternative to therapeutic abstention or conventional surgery.Hybrid therapy with SEW and TEVAR with TAAAD associated with major cerebral malperfusion should be considered, especially in patients for whom open surgery is extremely risky.Additional file 1: Video S1. Stepwise External wrapping procedure. A median sternotomy was made and cardiopulmonary bypass was established through femoral arterial cannulation and single two-stage venous cannulation via right atrial appendage. The ascending aorta was carefully separated from the main pulmonary arterial trunk and right pulmonary artery. Utmost care was taken during the dissection to avoid tearing the dissected aorta. Three pieces of an artificial graft were tailored, placed around the aorta from the coronary ostia up to the innominate artery, in a stepwise fashion, and approximated with a running suture so as to tightly wrap the ascending aorta. Then, Bioglue®  was applied around the graft to prevent oozing-type bleeding through the grafts and early graft migration.


We comment on the new challenges facing structural biologists, as they turn to describing the dynamic cascade of events that lead to replication origin activation and fork progression.This review discusses recent advances in single-particle cryo-EM and single-molecule approaches used to visualise eukaryotic DNA replication reactions reconstituted  In vitro reconstitution studies using budding yeast proteins revealed that the replication machinery is assembled in three temporally separated steps (in vitro reconstituted reactions that recapitulate DNA replication at cellular rates. We comment on how integrative single-molecule and cryo-electron microscopy (cryo-EM) approaches can provide unprecedented insights into the molecular mechanisms of DNA replication.Accurate transfer of genetic information from parental to daughter cells requires that chromosome replication is finely tuned, so that DNA is faithfully copied only once per cell cycle . Failureed steps  2–4]. F. FIn vitThe loading of a head-to-head MCM double hexamer establishes the symmetry required for bidirectional DNA replication. How the double hexamer is formed around duplex DNA has been the subject of intense debate. Both biochemical and structural work have shown that ORC binds and bends the DNA ,18. UponWhile helicase loading requires ATP hydrolysis by MCM, the double hexamer remains ADP-bound and does not unwind DNA ,10,11. HATP–CMG formation at origins fails to recruit the single-stranded binding protein RPA, indicating that additional components are required to establish a bidirectional replication fork . The Mcmin vitro reconstituted system; however, the mechanism is unknown [in vitro reconstitution experiments have failed to identify any role for Ctf4 in DNA replication per se [Not only does the CMG unwind the established DNA fork, it also serves as the organising centre of the replisome bringing together multiple DNA replication, genome and epigenome maintenance functions (reviewed in ,40, Figu unknown ,46. Enga unknown . Also po unknown , and ano unknown . Surprisn per se ,45, indin per se . A seconn per se . The monn per se . Ctf4 can per se ,58. Whiln per se , physican per se . MechaniIn silico reconstitution of double-hexamer formation using time-resolved cryo-EM has allowed for the visualisation of the structural intermediates that occur upon licensing of an origin of replication [lication . So far,lication ,36,60,61The precise nature of the molecular interactions between DNA polymerases and the rest of the core replisome is an important determinant in processes such as polymerase recycling and the mechanism of lagging-strand synthesis. Biochemical studies have revealed that the leading-strand polymerase Pol ε is tightly associated with the CMG helicase ,41,62,63The dynamics of the interactions between replisome components raise an immediate paradox. How can the replisome form a stable processive complex, while polymerases are easily exchanged? This same behaviour has been observed in other model systems and can be explained by the presence of multiple weak pair-wise protein–protein-binding sites linking polymerases with core replisome factors . In thisWe now understand that the Pol ε interaction with CMG is much more dynamic than originally suggested by the first cryo-EM imaging experiments, while Pol δ is emerging as a candidate component of the replisome core, in contrast with the textbook picture. Retention of Pol α and Pol δ over lagging-strand cycles has important implications for replisome coordination, presumably through the generation of priming, lagging-strand loops or a combination of both. Simultaneous observation of DNA looping and leading-strand synthesis during replication by T7 replisomes have demonstrated that most loop formation events occur during primer synthesis . Coordinin silico reconstitution techniques, have enabled the detection of sequential MCM helicase loading reactions on the minute timescale [The ability to describe the compositional and conformational dynamics of the advancing replisome is an important new challenge for structural biologists. Recent biochemical reconstitution combined with single-particle cryo-EM techniques have provided important insights into the mechanism of DNA replication. At the same time, real-time single-molecule imaging of individual replisomes have started to reveal unexpected kinetic and compositional dynamics at the replication fork. Thus, the development of new structural tools will be required to characterise the molecular choreography that control and maintain the replisome during chromosome replication. Time-resolved imaging approaches, combined with imescale . Other eimescale .In parallel, computational methods to tackle complex structural flexibility and compositional heterogeneity are being developed. Three-dimensional classification strategies and multi-body refinement are established, powerful techniques that can describe non-discrete conformational heterogeneity in large molecular assemblies . At the Importance of the field: Studying chromosome replication is key to understanding genome stability. To understand the concerted function of multiple enzymes that form the eukaryotic replisome, we must describe their structural dynamics.Current thinking: Time-resolved cryo-EM methods allow us to establish the sequence of molecular events that drive replication origin transactions. Single-molecule approaches describe the unexpected dynamics of replisome components, posing new challenges to structural biology.Future directions: Development of time-resolved methods with millisecond resolution will allow access to key short-lived structural intermediates on the path to replication fork establishment. In silico reconstitution methods will enable understanding the concerted action of multiple replication enzymes on the broader context of replication fork progression.


Early diagnostics and point-of-care (POC) devices can save people’s lives or drastically improve their quality. In particular, millions of diabetic patients worldwide benefit from POC devices for frequent self-monitoring of blood glucose. Yet, this still involves invasive sampling processes, which are quite discomforting for frequent measurements, or implantable devices dedicated to selected chronic patients, thus precluding large-scale monitoring of the globally increasing diabetic disorders. Here, we report a non-invasive colorimetric sensing platform to identify hyperglycemia from saliva. We designed plasmonic multibranched gold nanostructures, able to rapidly change their shape and color (naked-eye detection) in the presence of hyperglycemic conditions. This “reshaping approach” provides a fast visual response and high sensitivity, overcoming common detection issues related to signal (color intensity) losses and bio-matrix interferences. Notably, optimal performances of the assay were achieved in real biological samples, where the biomolecular environment was found to play a key role. Finally, we developed a dipstick prototype as a rapid home-testing kit. Point of care (POC) devices for self-monitoring of blood glucose are a life-changing technology and nowadays a norm for diabetes control. However, commercially available devices generally employ a relatively expensive hardware (reading system) and require a quite invasive sampling process (finger-pricks) involving a certain physical discomfort, especially for patients necessitating frequent measurements. It is worth mentioning that repeated finger-prick sampling also presents some risk, due to possible exposure to blood-borne pathogens and infections . For theAn interesting alternative currently attracting tremendous interest in the diagnostic community is the use of saliva as biological source . Saliva 2O2 that, via Fenton or Fenton-like reactions, transforms in the free radical form able to rapidly oxidize  the GNPs  present enormous potential for the development of a new generation of highly sensitive sensors , due to the GNPs . A colorthe GNPs .–) mediated particle reshaping, which allows for a rapid color change without any optical density (OD) loss, typically related to NP dissolution. Furthermore, we transferred our sensing technology onto a substrate, obtaining a rapid and highly sensitive colorimetric home-testing prototype for self-monitoring of salivary glucose levels.Here, to gain the high sensitivity necessary for rapid glucose detection at salivary concentration, we developed a novel strategy combining multibranched (spiky) GNPs, GOx, and bromine  compared to our aimed few-minute response  potentially able, in acidic conditions, to boost the oxidation process and promote a quick color change , MGNPs presented faster LSPR blue-shift when lowering the pH , while iodine ions led to drastic blue-shift, independently of H2O2 , producing Br2, Br3– and HBrO   .2  can also promote gold atoms migration from surface convexity to the concavity , leading to the more thermodynamically stable spherical shape . It may be envisaged that the surface atoms of the MGNP tips are less protected by the protein layer, thus being more prone to oxidation than the particle core. The structural changes are also promoted by oxidation of the salivary thiol ligands by Br2 , leadingdination . Furtheral shape . In thisThe reshaping process in saliva was also analyzed by TEM , confirmIn order to realize a portable home-testing device prototype, the sensing platform was transferred onto a solid substrate. Among the different materials tested , a porous nylon membrane was selected, presenting well structured (ordered) surface and a good balance between wettability and hydrophobicity see , enablinThe use of a solid substrate, led to a significant improvement of the reagents stability. While colloidal dispersions of MGNPs in water lose their morphological and plasmonic properties overtime, the on-substrate assay showed excellent stability up to 6 months, meaning that also the enzyme functionality was maintained see . An addiSaliva samples were tested with this dipstick-like colorimetric assay prototype as depicted in the schematics reported in After assessing hyperglycemic saliva and non-supplemented saliva (control), the substrates were analyzed by using reflectance spectroscopy  and scanThe assay prototype was finally optimized for analysis on real samples, considering that physiological glucose concentration in saliva is commonly <2 mg/dL (<130 mg/dL in human serum) while it is ≥4 mg/dL for hyperglycemic condition (≥160–200 mg/dL in human serum) . It is iFor this reason, aiming at an ON/OFF response as an alarm bell for healthcare, we set our threshold about ≥4 ± 0.5 mg/dL. For salivary glucose concentrations above this range values, the assay must produce an evident color change.To numerically estimate the colorimetric changes of our device and perform statistical data analysis, RGB coordinates of the substrate were acquired using a smartphone app see .A proof-of-concept experiment was performed measuring multiple saliva samples from different healthy donors with the addition of increasing concentrations of glucose from basal physiological values (<2 mg/dL) to hyperglycemic ones (4 and 6 mg/dL). A significant difference in the color variation was observed between physiological and hyperglycemic conditions by both naked-eye and RGB analysis, identifying our colorimetric threshold as ΔRGB ≥ 30 ± 10 see .ΔRGB values were also employed to measure the limit of detection (LOD). In this context, the assay performances were very good and reproducible using different independently produced devices to analyze the same saliva sample from a donor, reaching a LOD of 0.4 mg/dL see , in lineFurther validation of the assay prototype was performed through a small clinical study involving twenty different saliva samples, 12 from diabetic subjects and 8 from healthy subjects see . The anaThe nanoscale architecture of MGNPs and their sensitive plasmonic features were exploited for the development of a novel colorimetric assay for hyperglycemia, demonstrated to be effective in real saliva samples. Interestingly, the sensing platform, when operating in salivary medium, showed improved solidity and better dynamic range than in water, suggesting a proactive role of the biomolecular corona both in stabilizing the nanosensor and in promoting the reshaping process (instead of etching). The technological transfer from solution to the solid substrate finally led to the realization of a dipstick-like prototype for non-invasive self-monitoring of glycemia. The assay was finally validated as a rapid test (15 min) on various clinical samples, showing good reliability and, with further technological development, great potential for future home-testing applications. Overall, it is important to stress that the designed sensing platform could be easily adapted for the monitoring of several other pathologies, directly involving different oxidase enzymes.The raw data supporting the conclusions of this article will be made available by the authors upon reasonable request.The studies involving human participants were reviewed and approved by the Comitato Etico Regionale della Liguria. The patients/participants provided their written informed consent to participate in this study.All the authors contributed to the development of the ideas behind the work, experimental design, and manuscript writing.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


BACKGROUND AND PURPOSE: Hyperglycemia can lead to an increased rate of apoptosis of microglial cells and to damaged neurons. The relation between hyperglycemia and cerebrovascular markers on MRI is unknown. Our aim was to study the association between intraoperative hyperglycemia and cerebrovascular markers.METHODS: In this further analysis of a subgroup investigation of the BIOCOG study, 65 older non-demented patients (median 72 years) were studied who underwent elective surgery of ≥ 60 minutes. Intraoperative blood glucose maximum was determined retrospectively in each patient. In these patients, preoperatively and at 3 months follow-up a MRI scan was performed and white matter hyperintensity (WMH) volume and shape, infarcts, and perfusion parameters were determined. Multivariable logistic regression analyses were performed to determine associations between preoperative cerebrovascular markers and occurrence of intraoperative hyperglycemia. Linear regression analyses were performed to assess the relation between intraoperative hyperglycemia and pre- to postoperative changes in WMH volume. Associations between intraoperative hyperglycemia and postoperative WMH volume at 3 months follow-up were also assessed by linear regression analyses.RESULTS: Eighteen patients showed intraoperative hyperglycemia (glucose maximum ≥ 150 mg/dL). A preoperative more smooth shape of periventricular and confluent WMH was related to the occurrence of intraoperative hyperglycemia . Other preoperative cerebrovascular markers were not related to the occurrence of intraoperative hyperglycemia. Intraoperative hyperglycemia showed no relation with pre- to postoperative changes in WMH volume nor with postoperative WMH volume at 3 months follow-up.CONCLUSIONS: We found that a preoperative more smooth shape of periventricular and confluent WMH was related to the occurrence of intraoperative hyperglycemia. These findings may suggest that a similar underlying mechanism leads to a certain pattern of vascular brain abnormalities and an increased risk of hyperglycemia. Hyperglycemia occurs frequently during surgery and has been related to poor clinical outcome such as acute kidney injury, cognitive impairment and increased rates of wound infection resulting from compromised immune functioning As changes in brain structures may develop before cognitive decline becomes noticeable, detection of markers indicating neuronal damage is of particular interest. Studies in older individuals in the general population using magnetic resonance imaging (MRI) showed an association between hyperglycemia and a larger number of brain infarcts and more white matter hyperintensities (WMH) Studies investigating the relation between intraoperative hyperglycemia and cerebral markers on MRI are scarce. In our previous study, we found no association between intraoperative hyperglycemia and pre- to postoperative volume changes of the hippocampus and the hippocampal subfields, the frontal lobe, and frontal cortical thickness This is a further subgroup analysis of a previously published cohort Baseline demographic data and medical parameters including preoperative MMSE, prior history of diabetes, preoperative blood glucose levels and HbA1c were assessed before surgery. Blood samples were obtained preoperatively to determine fasting blood glucose levels. Perioperative parameters  were retrospectively recorded by chart review. Postoperative measures including length of intensive care unit stay, total length of hospital stay, and incidence of postoperative infections were documented. Intraoperative glucose minimum, maximum and mean were determined. As maintenance of a blood glucose level < 150 mg/dL is recommended in septic patients, where blood glucose levels above 150 mg/dL have been associated with cerebral damage, we defined hyperglycemia by at least one blood glucose measurement ≥ 150 mg/dL 3), a 3D susceptibility weighted gradient echo MRI sequence (SWI) , a fluid-attenuated inversion recovery sequence (FLAIR) , and a 2D EPI pseudo-continuous arterial spin labeling (pCASL) sequence . Presence of cortical, subcortical and lacunar infarcts was visually rated on the T1-weighted and FLAIR images by two experienced neuro-radiologists (JB and TW) according to the standards for reporting vascular changes on neuroimaging (STRIVE) criteria Participants were scanned on a 3T Magnetom TrioTim  MRI scanner. The MRI scanning protocol comprised a 3-dimensional T1-weighted sequence  for Matlab . WMH segmentations were performed on the registered 3D FLAIR images by the lesion prediction algorithm  of the lesion segmentation toolbox version 2.0.15  for SPM12. For longitudinal (pre- to postoperative) WMH volume analysis, volumes were calculated from the probabilistic WMH segmentations. Segmentation of the lateral ventricles was performed on the T1-weighted images using the automated lateral ventricle delineation toolbox (ALVIN) for SPM8. To classify the WMH segmentations, probabilistic WMH segmentations were thresholded at 10%. WMH within 10 mm from the lateral ventricles into the white matter were considered periventricular WMH. WMH that extended from periventricular to more than 10 mm into the deep white matter were considered confluent WMH. WMH that were located >10 mm from the lateral ventricles were considered deep WMH. If present, cortical infarcts were manually delineated by a trained researcher (IK) and removed from the WMH segmentations. Baseline WMH volumes and WMH shape markers were calculated from the thresholded WMH segmentations Determination of WMH volume and WMH shape have previously been described http://www.neuro.uni-jena.de/cat/index.html#About). CBF images were motion corrected and registered to the probabilistic gray matter volume maps. The CBF images were quantified with a single compartment model, after which the mean CBF was obtained for a total gray matter perfusion. All images were checked for image quality by a researcher (IK). Images that were classified as a good CBF contrast were used in the perfusion analysis. The no contrast images that contained noise only or large artifacts were excluded from further analysis.ASL images were processed with ExploreASL Baseline, intraoperative and clinical outcome data are expressed as median , or frequencies (%), respectively. Differences in frequencies were tested by the Chi-Square-test. Differences between groups in terms of continuous parameters were tested by using non-parametric Mann-Whitney-U test for independent groups.To assess the relation between preoperative cerebrovascular markers and intraoperative hyperglycemia, we performed multivariable logistic regression analysis adjusted for age and sex. The WMH shape marker analyses were also performed additionally adjusted for WMH volume, to assess whether the observed associations were independent of WMH volume. The regression analysis for WMH volume was additionally adjusted for total intracranial volume. We analyzed whether the occurrence of intraoperative hyperglycemia was associated with pre- to postoperative changes in WMH volume by linear regression analyses adjusted for age, sex, preoperative WMH volume and total intracranial volume. The association between intraoperative hyperglycemia and postoperative WMH volume at 3 months follow-up was studied by a linear regression model adjusted for age, sex and total intracranial volume at follow-up. In case of non-normally distributed data, all values were multiplied by 10,000 and then log transformed using the natural logarithm. IBM© SPSS© Statistics (version 25) was used for all analyses. A two-tailed P value ≤ 0.05 was considered to indicate statistical significance.Sixty-five patients were included into our analyses. Overall, 173 blood glucose levels were obtained ; p = 0.050] independent of age and sex. However, this association attenuated after additionally adjusting for WMH volume  ; p = 0.280; n=41] while adjusting for age, sex, baseline WMH volume and total intracranial volume. Three patients developed new cerebral infarcts at 3 months follow-up, two patients without intraoperative hyperglycemia and one with intraoperative hyperglycemia. As these numbers were too low, no comparative analyses were performed. Patients with intraoperative hyperglycemia showed no difference in postoperative WMH volume at the 3 month follow-up compared to patients without intraoperative hyperglycemia .We showed that a preoperative more smooth shape of periventricular and confluent WMH was related to the occurrence of intraoperative hyperglycemia. Other preoperative cerebrovascular markers were not related to the occurrence of intraoperative hyperglycemia. Intraoperative hyperglycemia showed no relation with pre- to postoperative changes in WMH volume nor with postoperative WMH volume at 3 months follow-up.To the best of our knowledge, our study is the first to study the association between WMH shape markers and hyperglycemia in the perioperative context. Few previous studies have been performed that assessed the shape of WMH in relation to clinical outcomes. In one previous study, de Bresser et al. found higher eccentricity of deep WMH in a frontal and parietal location in patients with diabetes compared to healthy controls Our results point out the relevance of investigating cerebrovascular markers in identifying patients who are vulnerable to intraoperative and postoperative adverse outcomes, such as hyperglycemia The majority of previous studies on the influence of hyperglycemia on other cerebrovascular markers have only assessed patients with diabetes Our findings might have clinical implications. There is evidence that hyperglycemia is associated with adverse clinical outcome, poor cognitive outcome in particular The strengths of our study are the prospectively collected MRI data including a follow-up at 3 months as well as the advanced assessment of WMH volume and shapes. Some limitations of the present study need to be mentioned. First, our study is limited by a relatively small cohort including only patients aged ≥ 65 years. Second, part of the data including intraoperative blood glucose measurements was obtained retrospectively, bearing the risk of missed patients who had hyperglycemia. Third, patients with intraoperative blood glucose measurement were potentially undergoing more extended surgery with a higher risk to develop intraoperative hyperglycemia or had more severe underlying conditions warranting intensive glycemic control and thus creating a potential selection bias in our dataset.In conclusion, our study is the first to investigate the association between cerebrovascular markers and intraoperative hyperglycemia. We found that a preoperative more smooth shape of periventricular and confluent WMH was related to the occurrence of intraoperative hyperglycemia. These findings may suggest that a similar underlying mechanism leads to a certain pattern of vascular brain abnormalities and an increased risk of hyperglycemia.Supplementary table S1.Click here for additional data file.


BackgroundImmobilization after hip reconstruction in children with cerebral palsy varies according to surgeon preference. The effect of postoperative immobilization on postoperative pain is unknown. Success in achieving hip stability and complications may also differ depending on the immobilization technique utilized.Questions/purposesUsing retrospective data, we aimed to evaluate: (a) what effect does postoperative immobilization with hip spica casting versus short leg casts and bar (SLCaB); have on pain and pain management in children with quadriplegic cerebral palsy undergoing femoral and/or pelvic osteotomy? and (b) Do complications and radiographic outcomes differ between those treated postoperatively with hip spica casting and those in short leg casts?Materials and MethodsChildren with quadriplegic cerebral palsy  undergoing femoral or pelvic osteotomy between 2012 and 2014 in the treatment of spastic hip subluxation were reviewed. Modes of immobilization were compared, between spica casting (n=15) and SLCaB (n=12). Preoperative, perioperative, and postoperative pain was quantified between groups. In-hospital epidural dosage, morphine equivalent dosages (MED), adjunctive medications, early maintenance of radiographic hip stability, and all complications were noted and analyzed.ResultsChildren were more likely to have spica cast immobilization if they were younger. Postoperative pain scores were similar between groups, with comparable patterns of epidural and MED administered during hospitalization. Spica casts were often flared up during hospitalization, but skin ulcers were uncommon and comparable between the two groups. Within 12 months of surgery, more ipsilateral femur fractures were observed distant to implants in the hip spica group, although the incidence of fractures did not meet statistical thresholds.ConclusionSpica casting and SLCaB after neuromuscular hip reconstruction did not show a difference in hip stability, narcotic pain medication usage or complication profile. The ideal post-surgical immobilization after femoral and pelvic osteotomy for children with cerebral palsy is debated, and practice varies widely. Current literature suggests hip spica casting is the most common method of immobilization for this population -10. TheoIn one retrospective investigation of hip reconstruction in cerebral palsy, complication rates for spica immobilization versus no casting were reported to be equivalent . Other iThe primary aim of this study was to compare pain and pain management in children with quadriplegic cerebral palsy undergoing femoral and/or pelvic osteotomy immobilized in either a hip spica cast or SLCaB. We hypothesized that those placed in hip spica casts would have lower pain scores and a reduced need for opioid medications compared to those placed in SLCaB forms of immobilization. The secondary aim of this study was to determine complications and radiographic outcomes in both groups.Study design and inclusion criteriaA retrospective cohort study was conducted to compare the effect of hip spica casting versus SLCaB on pain levels following proximal femoral and/or pelvic osteotomy surgery in the setting of neuromuscular hip subluxation. Individuals between the ages of three and 17 were included in the study if they had a diagnosis of quadriplegic cerebral palsy functioning at a Gross Motor Function Classification System (GMFCS) level IV or V, had neuromuscular hip dysplasia, underwent a femoral and/or pelvic osteotomy between 2012 and 2014, were immobilized postoperatively in either a spica cast or in SLCaB, and had a minimum of one-year follow-up. Individuals were excluded from the study if they had diagnoses other than cerebral palsy, GMFCS levels I-III, previous hip surgery, immobilization in a brace or pillow, a patient-controlled analgesia pump for pain control, or an epidural dosage differing from standard of care. All data were collected from a single tertiary care center, with inclusion of patients from one of nine pediatric orthopaedic surgeons.Compliance with ethical standardsAll procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards as well as the relevant regulations of the US Health Insurance Portability and Accountability Act. This study was approved by the Institutional Review Board of our local university and all data was collected at a single center. Informed consent was not required by our Institutional Review Board.Demographics and surgeryDemographic information collected included: age at surgery, gender, functional status, and underlying diagnosis. All femoral osteotomies were performed by a standardized technique and implant type: subperiosteal exposure, intertrochanteric osteotomy, and fixation with 90° or 100° blade plates utilizing three distal (subtrochanteric), bicortical cortex screws. The decision for use of spica casting or SLCaB was based on surgeon preference. Unilateral and bilateral procedures were included. Surgical and inpatient data included location and type of osteotomy, surgery duration, duration of inpatient stay, complications (classified according to Clavien-Dindo), and medications and dosing for the inpatient stay and discharge (described below) .Pain scores and medicationsPre-surgical pain level was defined as the most recent pain score within a year prior to surgery. Peri-operative pain scores were extracted in hourly intervals throughout the length of stay; the maximum daily pain score was used for analyses. Pre-operative pain scores were available for 22 children and peri-operative pain scores were available for all 27 children. Pain assessment scales routinely used in the clinic included the Faces Pain scale; Face, Legs, Activity, Cry, Consolability (FLACC), a numeric rating scale, or an observational scale -24. All Standard inpatient anesthesia consisted of an indwelling epidural catheter infusion of 0.1% ropivacaine with 1 mg/ml clonidine infused at patient-specific rates. Weight-adjusted epidural load (ml/kg) was calculated on an individual basis considering the rate of infusion, duration of use, bolus doses, and body weight. All medications that would potentially provide an analgesic effect administered between the time of surgery and discharge were recorded. Oral and intravenous pain medications were documented on an hourly basis in milligrams. Opioids were converted to morphine equivalent dosing (MED) using standard conversion tables, and a weight-adjusted daily total (MED/kg/day) was calculated for each postoperative day -26. StanPostoperative clinic visitsPostoperative pain was assessed at the first (approximately one month) and second (approximately three months) clinic visits in two ways: first, pain that was experienced since the last visit  and secondly, current pain levels on the day of the clinic visit. Postoperative pain data were available for 26 children at the first clinic visit and 25 at the second clinic visit. Secondary outcomes for clinic visits included: immobilization status, weight-bearing status, duration of immobilization, and complications . Fractures that occurred within 12 months of surgery were also noted, along with time to final follow-up.Orthopaedic outcomesThe orthopaedic-related outcomes of hip reconstruction were extracted from radiographs and medical records for all 27 children. Hip subluxation was assessed on anterior-posterior radiographs preoperatively and at three months post-surgery by Reimer’s Migration Percentage (MP), and dysplasia was assessed by the acetabular index . All comStatistical analysesDemographic data, surgical details, postoperative treatment protocols, radiographic measurements, fracture incidence, and complications were compared between the spica and SLCaB groups using two-sided t-tests or Mann-Whitney Rank Sum tests for continuous variables, and chi-square tests or Fisher exact tests for categorical variables. The incidence of additional surgeries and fractures were reported by individual children and the percentage of the group.Maximum daily inpatient pain scores (days zero to six), morphine , epidural loads , and other medications  were analyzed using two-way repeated measures ANOVA to determine the effect of treatment (spica versus SLCaB) and time (day of inpatient stay) as the repeated factor. Holmes-Sidak post hoc tests were performed when significant interactions were detected.A combined total sum of maximum pain scores and medication intake were calculated on an individual patient basis, and values were compared between groups using two-sided t-tests or Mann-Whitney Rank Sum tests. SigmaPlot  was used for all statistical analyses, with significance set at P<0.05.Demographics and surgeryOne hundred and sixty-four children had femoral or pelvic osteotomies in 2012-2014, and 27 individuals met inclusion and exclusion criteria  reported pain. Maximum pain scores during any specific inpatient day were not affected by the type of immobilization treatment  versus spica 33 ± 7 degrees (23-43 degrees), P=0.101). The pre-operative Reimer’s MP for the most subluxated hip was significantly different between groups, with the spica group having displaced hips (SLCaB 50 ± 12% (36-71%) versus spica 70 ± 20% (35-100%), P=0.010). Postoperative assessments of hip subluxation and dysplasia were performed on radiographs obtained a mean of 99 ± 57 days (range 36-261 days) after surgery. Four children in the spica group had an acetabular index >30 degrees compared to one child in the SLCaB group  compared to 0% with SLCaB , and 10/12 (83%) in the SLCaB group) had their implants electively removed between six months and two years postoperatively  in the spica group had a complication related to immobilization compared to three 25%) SLCaB patients (P=0.248). The majority of complications were Clavien-Dindo Grade I . The study was not powered to detect these differences, so while not statistically significant, the complication occurred at a sufficient rate to be clinically relevant (four of 15 patients) and demands further study. This complication may be related to immobilization-mediated osteopenia, as fractures occurred distal to the surgical implants after immobilization was discontinued. There was no consistently available pre-operative bone density evaluation or activity stratification such as stander use, so the effects of daily time in a standing position or underlying metabolic bone disease is unknown.Early radiographic outcomes of the hips at the second postoperative visit did not differ between cohorts, particularly the migration percentage, thus type of immobilization did not appear to compromise the early success of hip stabilization. Radiographic outcomes of hip reconstruction were likely a reflection of the quality and type of surgical intervention rather than the immobilization itself. Immobilization-related medical complications did not significantly differ between groups. Descriptively, the spica-casted group had more frequent casting adjustments in the peri-operative period; however, by the first follow-up visit those in spica casts had similar rates of pressure sores (two) compared to those in SLCaB (one). Non-immobilization related medical complications also did not differ between groups. Complications of spica casting have been well documented, with rates of skin complications approaching 30% in the treatment of femur fractures in developmentally normal children . HoweverThis study has several limitations. First, the study includes demographic differences between groups  and hips were more subluxated in the spica group, possibly influencing postoperative pain. Second, the data were collected retrospectively; thus, the results are specific to the sample and any generalizability should be made with appropriate caution. Third, the pain scores were collected using four different pain scales. Although all scales resulted in a pain score ranging from zero to 10, the anchors guiding responses differed as do the psychometric properties of the scales. This was unavoidable as these scales were collected clinically. Finally, potential confounding variables like disuse or pharmacologic-mediated osteopenia were not available for analysis and could have influenced the rate of fragility fractures.Despite these limitations, this is the first study of its kind to thoroughly evaluate immobilization types following hip reconstruction in children with quadriplegic cerebral palsy and the resultant impact on pain and orthopaedic outcomes. The current study suggests that there was no substantial difference in perceived pain, epidural dosage, MED administered or complication-related reason to choose one type of immobilization technique over the other. Based on this finding, future studies could be conducted prospectively in a randomized, controlled manner to further explore the impact of casting on recurrent pain during recovery, osteopenia, and determine whether individual patient characteristics could predict which immobilization technique would provide a better outcome or patient/family experience. Pain scores, analgesic administration, and complication profiles did not differ when comparing spica casting and SLCaB immobilization following hip reconstruction in this sample of children with quadriplegic cerebral palsy. Orthopaedic success of the procedure in stabilizing the hips was not related to an immobilization regimen. In our investigation, more children treated with spica casts experienced fragility fractures of the femur, but numbers were too small to draw definitive conclusions. Prospective studies with larger sample sizes are warranted to provide clinical recommendations.


A growing number of health care practices are adopting software systems that link with their existing electronic medical records to generate outgoing phone calls, emails, or text notifications to patients for appointment reminders or practice updates. While practices are adopting this software technology for service notifications to patients, its use for collection of patient-reported measures is still nascent.This study assessed the mode preferences, response rates, and mode effect for a practice-based automated patient survey using phone and email modalities to patients of primary care practices.This cross-sectional study analyzed responses and respondent demographics for a short, fully automated, telephone or email patient survey sent to individuals within 72 hours of a visit to their regular primary care practice. Each survey consisted of 5 questions drawn from a larger study’s patient survey that all respondents completed in the waiting room at the time of their visit. Automated patient survey responses were linked to self-reported sociodemographic information provided on the waiting room survey including age, sex, reported income, and health status.P<.001). Overall, response rates for those who selected an emailed survey  were higher (P<.001) than those who selected the phone survey . This held true irrespective of age, sex, or chronic disease status of individuals. Response rates were also higher for email (range 57.4% [58/101] to 66.3% [108/163]) compared with phone surveys (range 36% [23/64] to 43% [10/23]) for all income groups except the lowest income quintile, which had similar response rates  for phone and email modes. We observed moderate (range 64.6% [62/96] to 78.8% [282/358]) agreement between waiting room survey responses and those obtained in the follow-up automated survey. However, overall agreement in responses was poor (range 45.3% [43/95] to 46.2% [43/93]) for 2 questions relating to care coordination.A total of 871 patients from 87 primary care practices in British Columbia, Ontario, and Nova Scotia, Canada, agreed to the automated patient survey and 470 patients (45.2%) completed all 5 questions on the automated survey. Email administration of the follow-up survey was preferred over phone-based administration, except among patients aged 75 years and older (An automated practice-based patient experience survey achieved significantly different response rates between phone and email and increased response rates for email as income group rose. Potential mode effects for the different survey modalities may limit multimodal survey approaches. An automated minimal burden patient survey could facilitate the integration of patient-reported outcomes into care planning and service organization, supporting the move of our primary care practices toward a more responsive, patient-centered, continual learning system. However, practices must be attentive to furthering inequities in health care by underrepresenting the experience of certain groups in decision making based on the reach of different survey modes. The development of an information infrastructure to support a learning health system in primary care has advanced significantly with the application of advanced analytics applied to data from electronic medical records and routinely collected administrative data . HoweverA growing number  of healtThis cross-sectional study analyzed mode preferences, response rates, and respondent demographics for a short, fully automated, telephone or email patient survey to consenting individuals who had recently attended their regular primary care practice. Within our larger study, Transforming Community-Based Primary Health Care Delivery through Comprehensive Performance Measurement and Reporting (TRANSFORMATION), patients from 87 primary care practices in British Columbia, Ontario, and Nova Scotia, Canada, were asked to complete a waiting room survey between 2014 and 2016. The automated patient survey system was tested on a convenience sample of those participants who consented to receiving an additional postvisit survey by email or phone. Eligible patients had to speak English or French and have a valid telephone number or email address. Patients were asked to specify their preferred contact modality, phone or email, and provide their name and contact information to an on-site research team member.The contact information and unique identifying number for consenting patients was entered manually by survey administrators and uploaded to a cloud-based server via a software console. Upon receipt of the information, the administering information technology company collaborator, Cliniconex , programParticipants received an automated phone or email survey within 72 hours of visiting the practice. A phone survey response was recorded as completed only if the patient could be reached at the phone number on file, accepted the call, and completed all 5 survey questions. The phone survey was initially attempted twice, and then registered as incomplete if no answer was received. Partway through the study, the number of attempts was increased  to facilitate higher response rates. For those who chose an email survey mode, an email was sent once containing the introduction and a web link to the survey. An email survey was recorded as complete if all 5 survey questions were answered.Each survey consisted of 5 questions drawn from the TRANSFORMATION study’s waiting room patient survey . The queThe unique identifying numbers were used to link automated patient survey responses to self-reported sociodemographic information on the paper waiting room survey, completed during the participant’s visit to their practice, including age, sex, reported income, and health status.To detect any response bias inherent in using an automated email or phone survey system, we used Pearson chi-square tests to compare the sociodemographic profile of those who completed the automated patient survey (responders) with those who did not complete the automated patient survey (nonresponders). The comparison group of nonresponders contained those who either participated in the paper waiting room survey but refused the automated survey or agreed to the automated survey but did not complete all 5 questions. We also conducted Wilcoxon rank-sum tests on the paper waiting room survey responses, comparing differences in mean responses between those who completed the automated patient survey and those who did not. We conducted chi-square tests to compare automated patient survey mode preference (email or phone) and response rates both across and between patient sociodemographics. A Cochran-Armitage test for trends was also used to examine variation in mode preference by age and income. All analyses were performed using SAS software version 9.4 (SAS Institute Inc).The primary outcome measure response rate was pooled across all practices as we were interested in differences across dependent variables of age and attributed socioeconomic status rather than regional variations.To identify a potential mode effect, secondary analyses explored responses for each question across the 3 survey modes, email and phone (automated patient survey) and paper (waiting room). Test-retest analysis was undertaken, comparing each patient’s responses from the waiting room survey to their responses to the corresponding automated survey question. The percentage of concordant and discordant responses were determined by comparing waiting room derived responses with those from subsequent survey data. Weighted kappas were calculated to compare this concordance in survey responses by survey mode. Mean responses were also compared (using Wilcoxon signed-rank test) across responses to the corresponding questions from the paper waiting room survey and the automated patient survey .This study was approved by the behavioral research ethics boards at Fraser Health (RHREB 2015-017), University of British Columbia (H13-01237), Ottawa Health Science Network (20140485-01H), Bruyère Continuing Care (M16-14-029), and the Nova Scotia Health Authority (CDHA-RS/2015-150).Of those who agreed to the automated patient survey, 69.6% (606/871) of participants chose to receive the survey by email compared with telephone. This group represented 45.15% (871/1929) of the participants who initially consented to completing a paper waiting room survey . Of thosIn this sample, email administration of the follow-up survey was preferred over phone-based administration, except among patients aged 75 years and older . Among tWe observed moderate agreement between waiting room survey responses and those obtained in the follow-up automated survey see . HoweverWe successfully deployed an automated multimodal practice-based patient survey in 87 primary care practices. Overall, patient preference for the email survey mode was demonstrated; however, this was modified by age group and socioeconomic status. Indeed, completion rates for email were higher than most health care automated surveys . HoweverOur results show that the lowest income group had the lowest preference for the email mode and lowest response rate for the email survey while having the highest response rates for the phone survey. Our finding of the email responders being more likely to be female and of higher income echoes the pattern of a recent practice-based single-site email survey in Ontario . A move Opportunities to match surveys to reported language preferences and the capacity to reach people by phone or email who do not frequently attend a practice or have a stable home address raises the potential for an automated survey to be particularly valuable in understanding the experience of some of the most vulnerable members of a practice population. However, there are still inequities in access to the internet, with lower income individuals and people living in rural areas having lower access -14. TextThe low concordance rate of responses on questions of care coordination between paper and automated survey, especially the phone survey, raises important questions about a mode effect and/or the role of true anonymity in responding to questions about one’s health care provider or practice in a waiting room compared with online or automated phone response. It is also possible that the paper survey questions on care coordination sensitized participants to the issue, and after their visit, they were more aware of breakdowns in optimal care, accounting for their more negative responses with the automated survey following their practice visit. Additionally, the care coordination questions had negative phrasing, which may have been more confusing for phone responders.Cost-effectiveness was not the focus of this study. However, at two-thirds the completion rate compared with email, a phone survey would cost one and a half times as much. The cost of deploying a tailored automated patient outreach message and linked survey from the software company we collaborated with includes a 1-time practice start-up fee of $500 CAN (US $390) and an annual per-provider fee of $600 CAN (US $468). For an average practice of 4 providers and 5200 patients, an email survey would cost about 25 cents (US 20 cents) if each patient were sent a message and survey twice per year or less than 15 cents (US 12 cents) if most patients were sent a survey 4 times per year. Higher response rates make the approach more cost-effective for the email mode since automated systems frequently charge per survey sent. For quality improvement data collection, practices would not need to seek prior consent to contact patients. However, efforts to enhance patient buy-in and achieve higher response rates would be key to the cost-effectiveness of this approach. As practices seek better ways to engage patients and collect patient-reported experience measures and patient-reported outcome measures, it is essential to be sensitive to the response burden on patients and promote a culture in which patients understand the purpose of surveys and feel their insights and time are valued [The capacity of this proposed system to link collection of patient-reported measures with clinical services, such as appointment reminders or preventive care reminders, could improve the response rates received on general surveys of patient experiences, improving quality and reducing costs . Such anIncreasingly, electronic medical records are being used to collect patient-reported outcome measures that are inputted directly into the patients’ chart. This approach offers the benefit of supporting a patients’ immediate care. However, this approach creates a burden for the provider or practice to review data automatically put into a patient chart in a timely manner. Keeping a patient automated survey function distinct from clinical care may be attractive to providers and practices who need to manage their workflow and feel overburdened with data and data requests already.As a survey method, an automated patient survey offers some attractive features. Response rates and sample bias can be easily calculated for parameters such as age, gender or income as estimated by postal code without adding to patient burden of filling this information in. Based on continually updated information on filled surveys, ongoing distribution (sampling) parameters can be set to minimize or account for any bias that may arise. Automated surveys can be deployed at regular intervals determined by the practice and would not burden practice staff, providers, or even patients during a visit, thus avoiding interruptions or additional work.As more practices are collecting email addresses from their patients and patients expect email communication options, an automated patient engagement system with an embedded survey is feasible. Practices already using this or a similar technology to serve patients through outreach reminders may be more willing to participate in data collection initiatives that use this same infrastructure for quality improvement or research.There are some limitations to consider in interpreting the findings of this study. Initial recruitment into the TRANSFORMATION study was through a convenience sample of patients from primary care practices across British Columbia, Ontario, and Nova Scotia. As such, patients who were recruited into the study may not be representative of patients generally across Canada, potentially limiting generalizability. Additionally, potential for selection bias is further compounded by relatively low overall response rates by participants of the automated patient survey, who were recruited from the initial convenience sample of patients enrolled into the larger study.An automated practice-based patient experience survey achieved significantly different response rates between phone and email and increased response rates for email as income group rose. The higher response rates of the email surveys make a phone approach less cost-effective. However, care must be paid to furthering inequities in health care by underrepresenting the experience of certain groups in decision making. Further, potential mode effects for the different survey modalities may limit multimodal survey approaches.An automated communication system will become even more valuable as the stock of high-quality and validated instruments to measure patient-reported outcomes grows over the next decade . An auto


GBA) heterozygous variants are the most important genetic risk factor for the development of alpha-synucleinopathies . Herein, we report for the first time on a patient with a clinical diagnosis of Posterior Cortical Atrophy, carrier of the common GBA heterozygous variant N370S (c.1226A > G).Glucocerebrosidase (GBA gene (rs76763715), confirmed by Sanger sequencing. This is a relatively common variant, with predicted mild impact, already reported to occur in 2.4% of PD Italian patients; however, neither this nor other GBA variants have ever been reported to date in patients with Posterior Cortical Atrophy. Glucocerebrosidase activity was investigated and found to be significantly reduced (4.72 nmol/h/mg) compared to healthy controls as well as patients affected by neurodegenerative diseases, further supporting pathogenicity of the GBA variant.A 44-year-old woman with positive familial history for Dementia with Lewy Bodies disclosed three related signs characterizing the Balint’s syndrome: ocular apraxia, optic ataxia and simultanagnosia. Over 2-year follow up, overt gaze apraxia  appeared leading to functional blindness. Given her young age at onset and positive familial history, she underwent a next-generation-sequencing (NGS) based screening of a panel of 32 genes related to neurodegenerative conditions within the ANAMNESYS  study. NGS demonstrated the N370S variant in the GBA heterozygous variant N370S  determining reduced GCase activity. This report also confirms the role of NGS-based targeted gene analysis in detecting peculiar clinical phenotypes associated with known pathogenic mutations and reinforces the knowledge that carriers of genetic variants often present phenotypic overlaps across different neurodegenerative syndromes, highlighting the limitations of current clinical diagnostic criteria in defining boundaries between distinct conditions and the difficulties of clinicians in reaching the best clinical diagnosis.We report on a patient with a clinical diagnosis of Posterior Cortical Atrophy, carrier of the The online version contains supplementary material available at 10.1186/s12883-020-02023-5. GBA) heterozygous variants are the most important genetic risk factor for the development of Parkinson’s disease (PD) and Dementia with Lewy Bodies (DLB)  . Both PET studies were performed after 3 years of disease history, while SPECT DAT Scan was performed after 6 years of disease history. Despite several trials with different medications including levodopa, rivastigmine, memantine her clinical condition worsened. Over 2-year follow up, overt gaze apraxia  appeared leading to functional blindness, while increased tone and mild left bradykinesia remained stable. She never developed overt visual hallucinations, cognitive or motor fluctuations or psychosis. However, she continued to report vivid dreams and few episodes of persisting vivid dreams during awakening possibly suggesting sleep onset of REM episodes . The cognitive profile showing constructional apraxia with difficulties with clock and pentagons would be consistent with DLB. Furthermore, the Benton test was normal indicating unimpaired visuoperceptual function which is usually affected in classical early PCA. From the neuropsychological perspective, we would interpret this apparent discrepancy in terms of the different cognitive functions involved in performing a relatively “pure” visuo-perceptual task , in contrast with tests requiring a complex visuo-motor integration. From the clinical standpoint, patients with “focal” Balint syndrome exhibit non-homogeneous pattern of impairment, in which the three main signs of the triad are not represented to the same extent. This is also true when the syndrome relies on neurodegenerative mechanisms. In such cases some signs and symptoms may be prominent or relatively isolated at onset, before showing the progressive association with other signs able to complete the full picture of the syndrome. However, after excluding a diagnosis of DLB and based on the clinical findings the patient was diagnosed with PCA  . To the SNCA) as well as CNV in SNCA gene with MLPA analysis and it is very unlikely that a broader genetic test such as exome sequencing would have revealed variants of clear pathogenic significance in other genes. Additionally, we are not aware of other in vivo biomarkers possibly supporting a better clinical classification of our patient.Although our observation lacks of pathological confirmation and, thus, remains speculative, we can hypothesize that, in our patient, PCA is underlined by either Lewy body disease or corticobasal degeneration or mixed pathology. As a matter of fact, positive familial history would suggest a genetic variant with autosomal inheritance pattern as underlying cause of the proband’s neurological picture. Unfortunately, no other unaffected alive siblings consented to genetic testing. It is also possible that nigro-striatal involvement is not evident yet, given the peculiar phenotype of disease. Despite being relatively common in healthy population  , the patThis report also confirms the role of NGS-based targeted gene analysis in detecting peculiar clinical phenotypes associated with known pathogenic mutations and reinforces the knowledge that carriers of genetic variants often present phenotypic overlaps across different neurodegenerative syndromes, highlighting the limitations of current clinical diagnostic criteria in defining boundaries between distinct conditions and the difficulties of clinicians in reaching the best clinical diagnosis.Additional file 2. List of the genes included in the NGS panel and detailed cognitive evaluation.


During the coronavirus disease 2019 (COVID-19) pandemic, emergency providers are not only seeing an increasing number of patients with COVID-19 infections, but also associated complications and sequelae of this viral illness.We present the case of a 28-year-old female patient who presented after a confirmed COVID-19 infection with lower back pain, bilateral symmetric upper and lower extremity numbness, and urinary retention. The patient was diagnosed with acute transverse myelitis. She required intravenous corticosteroids and plasma exchange with significant improvement in symptoms and minimal residual effects.This case illustrates the importance of prompt recognition and treatment of sequelae of COVID-19 infections. The novel coronavirus pandemic has resulted in significant mortality and morbidity, with almost two million cases and over 100,000 deaths worldwide as of mid-April 2020.A 28-year-old female with a history of hypothyroidism on levothyroxine developed symptoms of productive cough, low-grade temperatures, low back pain, myalgias, and rhinorrhea during the novel coronavirus pandemic. She tested positive for COVID-19 via an at-home swab ordered by her primary doctor. Her upper respiratory symptoms resolved over the next week, but her lumbosacral back pain persisted and worsened, although without radiation. In addition, she developed paresthesias in her lower extremities, which progressed to total loss of sensation and with ascension of symptoms up to her mid-chest below the nipple line and bilateral upper extremities, as well as numbness to the tip of her tongue. She also reported approximately 48 hours of urinary retention as well as nausea and vomiting. She did not have any headaches, dysarthria or dysphagia, vision changes, or dyspnea. She was admitted to a large, academic, tertiary care center in Denmark.The patient’s neurologic exam was notable for symmetrically decreased sensation below the fifth thoracic vertebra level but preserved two-point discrimination and lower-extremity motor strength. She experienced decreased proprioception and four out of five strength in bilateral upper extremities with intact reflexes throughout. Lhermitte’s sign (electric shock-like sensation down the back triggered by bending the head forward) was positive and she had a wide-based gait. She retained 1.4 liters (L) of urine in her bladder, which was relieved after Foley catheter insertion. Lumbar puncture showed 125/per microliter (/μl) mononuclear cells (laboratory reference range 0–5/μl); 0.6 grams per liter (g/L) protein (laboratory reference range 0.15 to 0.6 g/L)); normal glucose (laboratory reference range 45–80 milligram per deciliter); negative antibodies; and gram stain and culture negative for infection. Magnetic resonance imaging (MRI) with and without contrast of the cervical, thoracic, and lumbar spine showed widespread elongated signal changes throughout the spinal cord to the conus medullaris and involving the medulla, with no disc pathology or spinal canal narrowing. These findings were consistent with longitudinally extensive acute transverse myelitis , thought to be reactive in the setting of recent COVID-19 infection. The patient was started on prednisolone and received two plasma exchange treatments with rapid improvement of symptoms. After eight days in the hospital, she was discharged on a steroid taper with improved symptoms including normal urinary function. Her residual symptoms included decreased sensation in the lower extremities up to the mid-thighs bilaterally.Transverse myelitis is a rare, acquired neurologic condition characterized by focal inflammation and injury of the spinal cord. There is a wide array of potential etiologies. Transverse myelitis is a recognized complication of viral or bacterial infections, although it can also be the first sign of neurologic conditions such as multiple sclerosis or neuromyelitis optica or associated with systemic autoimmune diseases such as lupus or sarcoidosis.6This patient presented with the hallmark symptoms of transverse myelitis including bilateral symmetric sensory changes and extremity weakness, lower back pain, and bladder dysfunction, and had classic contrast-enhancing lesions on MRI. Given the onset of these findings in the setting of a confirmed COVID-19 case, as well as her marked improvement with steroids and plasma exchange, it is likely that this was an autoimmune-mediated response to the novel coronavirus. Furthermore, she had no visual symptoms such as eye pain or vision loss that are classically seen in multiple sclerosis or neuromyelitis optica, nor the immunoglobulin G auto-antibodies or oligoclonal bands that are the immunological hallmarks of these diseases.8What do we already know about this clinical entity?Transverse myelitis is a rare neurological condition causing inflammation of the spinal cord and is believed to develop via autoimmune mechanisms.What makes this presentation of disease reportable?Transverse myelitis is a known sequelae of viral illnesses such as influenza, but has heretofore not been associated with novel coronavirus infections.What is the major learning point?Patients can develop serious complications with lasting neurological effects even after initial recovery from novel coronavirus infection.How might this improve emergency medicine practice?Emergency providers can prevent significant morbidity by recognizing post-infectious complications of novel coronavirus, including transverse myelitis.As the number of COVID-19 infections continues to rise, more patients are presenting to the emergency department with novel coronavirus-related symptoms and associated complications. Healthcare workers, especially emergency providers on the frontlines, treat these affected patients and bear witness to their different presentations and clinical courses. This case report emphasizes the importance of remaining cognizant of the atypical and less-prevalent sequelae of viral infections in patients with recent or concurrent COVID-19 infections, as prompt recognition and management are important to prevent significant morbidity. It also highlights that young and otherwise healthy patients who have seemingly recovered from COVID-19 infection can still develop serious complications. These are important takeaways for emergency providers in the midst of providing care during this global pandemic.


Drosophila melanogaster, reveal a diversity of underlying mechanisms. In this review, we will discuss three recent studies that expand our understanding of the molecular features governing CC. In particular, we will focus on a molecular fitness fingerprint, oncogenic pathways, and the importance of cell junction stability. A fitness fingerprint, mediated by flower (hFWE) protein isoforms, dictates that cells expressing the flower-win isoforms will outcompete adjacent flower-loss-expressing cells. The impact of the flower protein isoforms is seen in cancer progression and may have diagnostic potential. The yes-associated protein (YAP) and TAZ transcription factors, central mediators of the oncogenic Hippo pathway, elevate peritumoral fitness thereby protecting against tumor progression and provide a suppressive barrier. Similarly, COL17A1 is a key component in hemidesmosome stability, and its expression in epidermal stem cells contributes to fitness competition and aging characteristics. The contributions of these pathways to disease development and progression will help define how CC is hijacked to favor cancer growth. Understanding these features will also help frame the diagnostic and therapeutic possibilities that may place CC in the crosshairs of cancer therapeutics. Cell competition (CC) is a feature that allows tumor cells to outcompete and eliminate adjacent cells that are deemed less fit. Studies of CC, first described in  The ability of incipient cancer cells to overcome cellular and microenvironmental constraints depends on their ability to selectively rewire cell autonomous and cell non-autonomous attributes. These attributes, often referred to as the hallmarks of cancer, constitute the abilities acquired during multistep development of human tumors . Recent Drosophila melanogaster by comparing the growth rates between cells carrying mutations in genes encoding ribosomal proteins (Minute+/−), and wild-type cells (Minute+/+) [Minute wildtype cells outcompeted and eliminated Minute heterozygous cells in flies that contain both cell types. However, Minute mutant cells, in the absence of wildtype cells, remained viable, thereby uncovering a non-cell autonomous molecular mechanism contributing to CC [Minute-mediated CC in Drosophila, recent CC mechanisms have been identified in mammalian orthologs through a molecular fitness code, paradoxical oncogenic activation, and cell junction stability [The first molecular component of CC was identified in nute+/+) ,7. Minutng to CC . In additability ,9,10. Drosophila [A recent study associated CC with a molecular fitness fingerprint of the flower (hFWE) protein , which wosophila . In humaosophila . Madan eUsing a CRISPR-mediated hFWE knockout system in a breast cancer cell line, the authors were able to control the expression of individual hFWE isoforms and determine that each isoform alone did not alter cell proliferation or cell death. However, coculture of hFWE loss-expressing cells with win-expressing cells resulted in caspase-dependent apoptosis of the hFWE loss-expressing cells. This phenomenon was also determined to be cell-cell contact-dependent as conditioned media did not have a similar apoptotic effect .Analysis of human tissues showed that all hFWE isoforms were expressed at low levels in normal tissue, but malignant and associated stroma exhibited a more diverse and spatially distinct pattern of hFWE expression. The primary tumor tissue was abundant for the win isoform, while the associated stroma expressed more of the loss isoform. Loss expression was found, in conjunction with elevated apoptotic genes, to be more prevalent in the layers of the stroma adjacent to the tumor tissue. Overall, both win and loss isoforms were poorly expressed in normal tissue, but this study showed that win was consistently expressed in tumor tissue and hFWE loss was more abundant in the stroma .To address the functional impact of these observations, the authors showed in vivo that the knockdown of hFWE expression by RNA interference in tumor tissue reduced tumor volume and the probability of metastasis. The effect of knocking down hFWE in this system was completely rescued by ectopic hFWE Win expression. Conversely, over expression of the win isoform led to a significant increase in tumor growth .To address the therapeutic potential of targeting hFWE, mice with hFWE knockout tumors were treated with mainstay therapies, including fluorouracil or cisplatin with docetaxel. Cancer cell lines with both high and low expression of win isoforms were subject to hFWE knockout and chemotherapy treatment in vivo. The combination resulted in a significant synergistic decrease in tumor volume and metastatic potential compared to each individual treatment alone .This study identified a molecular code for a cell’s fitness fingerprint, showed its importance in cancer progression, and uncovered its potential therapeutic application. Interestingly, hFWE expression has also been linked to cancer incidence using models of skin papilloma . TogetheDrosophila [The Hippo pathway is a common regulator of cell proliferation, cell survival, and organ size that is stimulated by cellular contact, stress, and growth factors. It is consistently identified as an oncogenic driver and, similar to the flower protein, was first discovered in osophila ,13. Downosophila . HoweverUsing a mouse model of induced intrahepatic cholangiocarcinoma (CCA) via Notch and Akt activation, the authors demonstrate that these tumors had elevated levels of YAP and TAZ with the expected upregulation of genes coding for cell proliferation, stress response, and wound healing. Hepatocytes of normal livers were barely detectable for YAP and TAZ. However, the hepatocytes surrounding the tumor tissue also exhibited YAP accumulation. Adeno-Associated Virus-Cre-mediated peritumoral ablation of YAP in this model showed accelerated tumor growth, suggesting that peritumoral YAP was acting to suppress further tumor progression. Furthermore, deletion of an endogenous YAP and TAZ negative-regulator, LATS1/2, in the surrounding tissue significantly reduced tumor burden, indicating that heightened YAP in the peritumoral tissue can restrain tumor growth. The simultaneous quadruple deletion of YAP, TAZ, and LATS1/2 in the peritumoral tissue increased cancer cell proliferation and tumor burden. Finally, activation of YAP and TAZ in the peritumoral tissue triggered non-apoptotic tumor cell death . These dAs expected, ablation of tumoral YAP and TAZ greatly reduced tumor volume to a few residual tumors and almost completely eliminated the tumor. This confirms that YAP and TAZ are required for tumor maintenance when surrounded by WT hepatocytes. To analyze the tumor suppressive properties of YAP and TAZ in a metastatic tumor, the authors injected mice with melanoma-derived tumor cells that would home to the liver. Nearly 100% of the metastatic melanoma-based tumors were reduced upon peritumoral hepatocyte activation of YAP and TAZ. This showed that the CC mechanism of YAP and TAZ could be applied to both primary and migrant tumors .Moya et al., 2019 showed that the Hippo pathway, specifically YAP and TAZ, elevate peritumoral fitness, thereby making these cells better suited to fend off the tumor cells. This paradoxical discovery identifies a robust tumorigenic pathway having space-specific tumor-suppressive properties. These results are consistent with other recent reports showing that YAP plays a major CC role in mouse development and in canine epithelial cells ,16. HippAs we age, stem cells that once replenished our damaged skin become exhausted. This results in skin atrophy, fragility, impaired healing, and dyspigmentation ,19. An iA genetically modified mouse model capable of tracing epidermal stem cells with different colors was used to show that the balance and number of stem cell clones was lost as the mouse aged. Moreover, the size of the dominant clones was correlated with high COL17A1 expression. These data suggest that COL17A1 may play a significant role in stem cell maintenance. Expanding on this concept further, the authors incorporated a COL17A1 knockout while tracing epidermal stem cells. Both heterozygous and homozygous COL17A1 knockout cells were significantly eliminated in the presence of wildtype cells and were eliminated from the epidermis. An in vitro 3D cocultures of keratinocytes having COL17A1 knockout plated at a 1:10 ratio with wildtype showed a significant elimination of COL17A1 knockout cells. These data showed that differential expression of COL17A1 contributes to CC [The authors coupled the mechanism of COL17A1-mediated CC to the renewal properties of stem cells. It was observed that COL17A1 knockout cells divided asymmetrically perpendicular to the basement membrane, resulting in diminished renewal with concomitant epidermal thinning. Forced expression of COL17A1 rescued epidermal thinning, micro-delamination, and basal cell flattening. Impaired wound healing observed in the COL17A1 knockout mouse was also rescued by expression of COL17A1 in basal keratinocytes. Furthermore, compounds that could induce COL17A1 were identified and their administration increased colony number and size in a colony formation assay. Similar studies on skin morphogenesis revealed that cells with low Mycn are eliminated by CC either during early epidermal stratification or later in the differentiating epidermis . TogetheCC is an important biological phenomenon and seems to be regulated by multiple mechanisms. A cohort of factors recently found to mediate CC include the hFWE protein isoforms , the YAP


Among older adults without cognitive impairment, a novel advance care planning group visit (ACP-GV) intervention increased ACP documentation and readiness to engage in ACP. A key question is whether an intervention can be adapted to support people with mild cognitive impairment (MCI) and a family care partner. We used a human-centered design process, rapid-cycle prototyping, and qualitative methods to adapt an ACP-GV intervention to individuals with MCI and a study partner. In 2019, we convened a longitudinal cohort of six patient-study partner stakeholders in three focus groups to suggest intervention adaptations. We also conducted a single arm study of four ACP-GV interventions  that were iteratively refined with input from the longitudinal focus groups and intervention participant feedback. Decision tools, resources and videos were used to describe the concept of ACP and flexibility in selecting a medical decision maker. Many ACP-GV participants strongly agreed that the group discussion gave them useful information (81%) and would recommend the ACP-GV to a friend (85%). Pre- and post-ACP readiness surveys indicated that participants were significantly more ready to talk to their medical decision maker about ACP (p=0.028), while study partners perceived their loved ones less ready to speak to their doctor about ACP following the intervention (p=0.031). Use of rapid prototyping allowed testing of different resources and tools aimed at helping individuals with MCI and their study partners discuss ACP. Future work is needed to understand the feasibility of implementing an ACP-GV intervention for individuals with MCI into clinical settings.