Both univariate and multiresponse multinomial ordered probit regression models were utilized across outcome domains to quantify associations between outcomes and spending. We found that MSPB was not associated with quality of care in most cases, adding evidence of a lack of outcome accountability among Medicare-funded facilities. Furthermore, worse outcomes were found to be associated with increased spending for some metrics. Policies are needed to align quality of care outcomes with the increasing costs of U.S. healthcare.The cost of healthcare in the United States has increased over time. However, patient health outcomes have not trended with spending. There is a need to better comprehend the association between healthcare costs in the United States and hospital quality outcomes. Medicare spending per beneficiary (MSPB), a homogeneous metric across providers, can be used to evaluate the association between episodic Medicare spending and quality of care. Fifteen inpatient outcome measures were selected from Hospital Compare data among all ( The cost of healthcare in the United States has steadily increased over time . More reHealthcare quality is arguably more important than healthcare costs, covering aspects of effectiveness, safety, a culture of excellence, and desired outcomes . The U.SResearch on the associations between healthcare spending and quality has led to inconclusive results . HoweverHigh spending may be attributed to payers adopting costly technologies and treatment methods that may not be more effective than already established technologies or methods  or justiThrough the Hospital Quality Initiative, the Centers for Medicare and Medicaid Services (CMS) seek to assist hospitals with improving their quality of care. Accordingly, the CMS provide public datasets through their Hospital Compare (recently renamed to Care Compare ) databasMedical spending depends on a large range of factors, such as geographic practice cost differences, wage differences, or disease- and patient-specific factors. Therefore, adjusting for those measures is paramount to assessing the links between spending and health outcomes. Medicare spending per beneficiary (MSPB) is a measure used to compare facilities by standardizing the cost per covered individual within the Medicare health insurance plan. This price-standardized and risk-adjusted measure homogenizes the Medicare-funded spending per beneficiary across an episode of care initiated from a hospital inpatient stay . TherefoWith standardized measures of spending and quality of outcomes available, it is important to understand the association between spending and outcomes at the facility level across the United States. The relationship between cost  and quality is bidirectional. Inpatient complications may lead to return visits to acute or ambulatory facilities, resulting in higher episodic spending, while higher utilization through improved coordination of care in the larger patient episode may have an impact on 30-day outcomes where the MSPB and quality episodes overlap . In order to explore this research question, this manuscript assesses the associations between medical spending, as reflected in the standardized MSPB measure, with a series of standardized national outcomes available through CMS Hospital Compare.n = 4758 facilities were used in this study [CMS Hospital Compare data for 2019 corresponding to is study . Metricsis study . These fWithin the complications, deaths, and unplanned visits group within this analysis, the 13 quality measures included: 30-day mortality associated with heart failure, acute myocardial infarction (AMI), coronary artery bypass graft, stroke, pneumonia, and chronic obstructive pulmonary disease ; overall 30-day readmission rate (identified by READM); and healthcare-acquired infections associated with catheter-urinary tract infection, central-line-associated bloodstream infection, colon surgery, abdominal hysterectomy, Methicillin-resistant Staphylococcus aureus (MRSA), and Clostridium difficile (C. diff) infection (identified by the variables HAI 1–6).Cohort-specific risk-standardized 30-day mortality, a quality indicator established by the Yale Center for Outcomes Research and Evaluation (CORE), represents all-cause mortality within 30 days from discharge among patients who were discharged from the hospital . The morAppropriate care provided for disease-specific conditions in the initial hospitalization can reduce hospital readmissions and healthcare costs . The CMSEach HAI measure reports infection using the standard infection ratio (SIR) for observed infection for patients in a bed. The Centers for Disease Control and Prevention (CDC) attributes increased hospital costs to HAIs, providing justification for inclusion of this measure in the analysis . FurtherUnlike the aforementioned outcome measures, the Patient Safety Indicator Composite (PSI-90) is a composite score using a weighted average of the observed-to-expected ratio for several other health outcome measures, such as pressure ulcer rates or deep vein thrombosis . PatientPatient experience is also a quality outcome measure included in this study. The HCAHPS survey consists of 32 questions related to hospital care and is completed by patients following an inpatient stay. This measure provides the patient’s perspective in determining quality. Results are ranked on a Likert scale from 1 (worst) to 5 (best). The summary star rating for a facility (identified by the variable PAT_EXP) is derived by computing the mean average of 10 HCAHPS measure star ratings: hospital rating, willingness to recommend the hospital to others, hospital cleanliness, hospital quietness, nurse communication, doctor communication, discharge information, care transition, hospital staff responsiveness, and communication about medication .Data for continuous outcome variables were transformed to categorical ordered quintiles to reduce the influence of outliers and provide a homogeneous parameter interpretation across outcomes, aligning outcome scales to that of the patient experience HCAHPS star ratings . Imputation of missing MSPB was considered, but small differences in resulting sample sizes with respect to the complete case analyses did not justify the approach.Five domain models were defined assessing the association of MSPB with (1) six healthcare-associated infections (HAI domain model), (2) six 30-day mortality rates , (3) 30-day readmission rate (30-day readmission domain model), (4) patient safety index , and (5) patient experience HCAHPS star rating (patient experience domain model). Only hospitals with complete within-domain outcome metrics were used to avoid outcome imputation and define homogeneous sets of facilities with all available domain-based outcome metrics. Additionally, missing outcomes are not due to lack of reporting but, more importantly, because those measures are not applicable for those facilities .A multiresponse multinomial ordered probit model  was usedA sensitivity analysis was performed employing a single model combining all five domains—i.e., all 15 quality outcome measures—to assess the potential benefit of accounting for cross-outcome correlations among outcomes from different domains, as opposed to only within-domain correlations. R statistical software version 4.0.3 was used across all analyses.n = 495 vs. n = 492, respectively). With such a small difference, results using a complete case analysis are reported for the primary and sensitivity analyses.n = 680) and 30-day mortality outcomes (n = 982) in the multi-outcome domains, as well as the univariate models across single-outcome domains. Using a Bonferroni multiple testing corrected significance level of 0.0033 (across univariate and multivariate domains), MSPB was found to be significantly associated with MRSA bacterium HAI (HAI5) (p < 0.0001) and 30-day mortality among AMI (p = 0.0025) patients within the HAI and 30-day mortality quality domains, respectively. MSPB ratios are therefore positively associated with MRSA bacterium rates as well as its 30-day mortality rate among AMI patients.n = 4390), patient safety (n = 3210), and patient experience star rating (n = 3406) outcome quality domains are also included in p < 0.0001) and patient experience as measured by the HCAHPS star rating (p < 0.0001). A statistically significant positive association exists between MSPB and 30-day all-cause readmission rate; however, there is a significant negative association between MSPB and HCAHPS patient experience star rating.Across the univariate domains, the estimated associations between MSPB and the 30-day readmissions (n = 492) report measures across all outcomes versus domain-specific analyses.Results of the sensitivity analysis combining all five domains—i.e., all 15 quality outcome measures—into a single model to assess the potential benefit of accounting for cross-outcome correlations among outcomes from different domains are provided in Significant positive associations were found between Medicare spending per beneficiary and 30-day mortality rate among AMI patients, MRSA bacterium healthcare-associated infection rate, and 30-day all-cause readmission rate in the primary analysis. While the association between 30-day readmissions and MSPB is expected, as readmissions are included in the MSPB spend episode , it corrSome studies that have looked at the relationship between AMI mortality rates and Medicare spending found that mortality rates decreased as spending increased ,41, whicOver three quarters of U.S. hospitals are paid under the Medicare Inpatient Prospective Payment System (IPPS) . HospitaOur study found a negative association between the HCAHPS summary star rating, which is a measure of patient satisfaction, and Medicare spending, in line with prior research . A 2017 Measures are not always applicable to all facilities, which leads to varying sample sizes per outcome. While the results were grouped by domain in an effort to address this problem, there is still a large number of potentially smaller facilities for which results are not available in the larger outcome domains. The results are not generalizable to all hospitals due to the level of missingness of information, as well as the possibility that it is not missing at random. For example, smaller hospitals would not report surgical outcomes if no surgeries were performed.Only claims for beneficiaries admitted to eligible acute care inpatient hospitals (paid through IPPS) during the period of performance are included in the calculation of the MSPB measure . While tWhile other covariates could be of interest in risk adjusting quality outcomes, such as location , they are not necessary given the scope of this study. The primary research question relates to whether higher episodic spending as captured by the MSPB measure has a statistically significant association with quality outcomes. MSPB already accounts for financially justifiable measures such as wage or general costs, and factors such as rurality may explain but not necessarily justify worse outcomes.Another potential unaccounted factor is how quality of outcomes relates to hospital size, type of hospital, location, and patient access to care. LaPointe describes the challenge of providing quality care with high-cost, low-volume services to patients with limited access to care, poor socioeconomic status, and greater health disparities .While the granularity of this study is at the hospital level, further information at the patient level that is currently unaccounted for in the outcome measures may help to explain some of the hospital-level variability. Hence, hospital-level information may lead to different associations between costs and outcomes than complete patient-level information, if available at a national level.Future research using data at the patient level would help to confirm the findings and account for other factors that may not be captured in hospital level outcomes, including a wide range of social determinants of health. Additionally, further research is needed to investigate causal factors behind the association between MRSA and MSPB given that they are not driven by misaligned incentive systems, since the CMS do not pay for treatment of hospital-acquired infections. Finally, further research is also needed to understand the association between patient satisfaction and MSPB, since our findings do not show an anticipated positive linkage between increased MSPB and greater patient satisfaction. If higher costs do not translate into greater patient satisfaction, there is evidence of room for efficiency improvements in spending.Healthcare consumers, providers, and funders could benefit from a better understanding of (dis)connections between quality of care and episodic cost. Hospitals would be able to target those hospital-based outcomes associated with higher episodic cost. Patients would benefit from enhanced outcomes while consuming fewer resources within the continuum of care. The disconnect between higher spending and outcomes, in addition to spiraling overall healthcare costs and subpar healthcare outcomes, deserve further and deeper analysis and policy changes to support and adequately reward financial and healthcare efficiency.


Germ cell teratomas belong to non-seminomatous germ cell tumors and account for 95% of malignant testicular tumors. Regarding the current World Health Organization (WHO) criteria, testicular teratomas are divided into prepubertal and post-pubertal subtypes based on patients’ age. The term “burned-out testicular tumor” is a very rare condition referring to a regressed testicular tumor which presents with its metastases without any clinical finding in the testicle. Metastasis can be the presentation of post-pubertal teratoma in 22-37% of cases. In scar associated teratoma (burn-out component), the metastasis rate is 66%. We reported a rare case of post-pubertal teratoma in a 34-year-old male who presented with multiple liver masses initially. Liver biopsy revealed poorly differentiated adenocarcinoma probably of gastrointestinal (GI) tract origin. The upper and lower GI endoscopy were normal. Scrotal ultrasonography showed a hypoechoic cystic intratesticular lesion in the left testis. The patient underwent radical orchiectomy and the histopathologic examination revealed post-pubertal teratoma with burned out component. The patient underwent proper treatment and is still under follow up. As a result, in a young male patient who presented with a retroperitoneal mass or poorly differentiated carcinomas of an unknown primary site, using light microscopy and immunohistochemical profiling alone may be inadequate. Therefore, scrotal screening and physical examination of the scrotum and bilateral testis should be considered to exclude possibility of a metastatic progression from a testicular germ cell neoplasia. Germ cell tumors (GCTs) account for 95% of the malignant testicular tumors. Seminomas tumors consist 40% to 50% of GCTs . Non-semTesticular teratomas are divided into prepubertal and post-pubertal subtypes based on the current World Health Organization (WHO) criteria. This categorization generally corresponds to the patients’ age in relation to puberty; however, age categorization of prepubertal-type teratoma results in combining tumors with different pathogenesis and clinical behaviors . Post-puIt is well recognized that a small subset of testicular germ cell tumors, including teratomas, undergo partial or complete regression (<5%), which results in a well-defined nodular scar or fibrosis in testis. These patients may present with metastases and nonspecific findings on testicular ultrasound. Histologically, regression is characterized by a fibrotic scar with variable lymphoplasmacytic inflammation, ischemic “ghosts” of hyalinized tubules, increased number of small blood vessels, hemosiderin-laden macrophages and coarse intratubular calcifications .The phenomenon of a primary testicular germ cell tumor (TGCT) outgrowing its blood supply and undergoing auto-infarction has been described as a ‘burned out’ TGCT. Despite the spontaneous regression of the primary testicular tumor, approximately 50% of ‘burned out’ primary testicular tumors continue to harbor malignant cells and distant metastatic disease and can progress. The metastases of testicular germ cell tumors mainly develop through lymphatic route. Only pure choriocarcinoma is spread through haematogenic pathway .It may be difficult to determine the source of metastasis when the testicular tumor is totally regressed . IdentifHere we discuss a case of post-pubertal teratoma with ‘burned out’ component presenting as multiple liver masses. The importance of this case is related to the rare presentation of this phenomenon and the importance of carrying out a systematic testicular ultrasound examination in case of metastasis in a young man.A 34-year-old man presented with left upper quadrant pain. An abdominal computed tomography (CT) scan and sonography showed multiple liver masses. He underwent liver core needle biopsy in another center and based on immunohistochemistry study (positivity for CK20 and CDX2 with negativity of CK7) the diagnosis was a poorly differentiated adenocarcinoma probably originated from GI tract. Therefore, he underwent multidisciplinary investigations to elucidate tumor origin, including upper and lower GI endoscopy and abdominal and lung CT scan. All of the assessments as well as laboratory testing for tumor markers, including testicular tumor markers, were normal. There was no abnormality in the physical examination of the scrotum. However, scrotal ultrasonography showed a hypoechoic cystic intratesticular lesion in the left testis. He underwent a radical left orchiectomy. On gross examination, the testicle measured 5×3.5×3 cm. Tunica vaginalis and albuginea and spermatic cord showed no gross abnormalities. Cut surface revealed a well-defined multicystic lesion measuring 2×1×0.8 cm, confined to the testis. Microscopic examination exhibited multicystic spaces lined by gastrointestinal and respiratory type epithelium with foci of apocrine metaplasia . Areas oAlthough testis cancer is rare , it is the most common cancer in young men. Majority (90 % to 95%) of all primary testicular tumors develop from germ cells .Based on the current WHO criteria, testicular teratomas are divided into prepubertal and pos-tpubertal subtypes . Post-puMajority (approximately 90%) of post-pubertal testicular teratoma are associated with germ cell neoplasia in situ (GCNIS) in contrast to prepubertal type which shows no association with GCNIS . FurtherThe term “burned-out testicular tumor” refers to a regressed testicular tumor which presents along with metastases . Prym fiClinical manifestations generally depend on the metastatic disease. Only a few non-metastatic cases were diagnosed with signs and local symptoms, including pain in the scrotal sack, testicular shrinking and infertility .The two main hypothesized mechanisms for this regression include cytotoxic T lymphocyte mediated immunological response and ischemic response due to reduced blood supply. Cytotoxic T lymphocyte mediated immunological response recognizes tumor antigens and destroys malignant neoplastic cells with subsequent fibrosis replacement. On the other hand, ischemic response occurs in the tumor due to blood supply deficit, which might be due to one or a combination of tumor cell high metabolic rate or intermittent testicular torsion .Existence of testicular tumors cannot be confirmed or excluded solely through palpation. Therefore, supplemental studies with ultrasound are mandatory . UltrasoThe sensitivity of the testicular ultrasound for diagnosing GCT is nearly 100%, therefore, all young patients with metastasis, including retroperitoneal, mediastinal or liver massed, should undergo testicular ultrasonography. The characteristics of testicular tumor regression are not specific and may include hypo or hyperechogenic area, sometimes with calcification and fibrosis corresponding to tumoral scar .Tumor marker assessments are necessary in the diagnostic approach of testicular tumors, staging, treatment and follow up, depending on the histological lineage and the response to treatment .The diagnosis is anatomopathological. The microscopic findings in our study were in line with the WHO diagnostic criteria for testicular tumor regression, including inflammatory lymphoplasmacytic infiltrate (90% of cases), tubular hyalinization (approximately 70% of cases), increased vascularity (50% of cases), hemosiderin (44% of cases) and thick intratubular calcifications. The non-tumoral areas of our case also showed features of atrophy and sclerosis of the seminiferous tubules (100% of cases), germinal cell malignancy in situ (approximately 50% of cases) but no hyperplasia in Leydig cells (45% of cases) or intra-tubular microliths (30% of cases) is seen (In the approach of this young male patient with metastasis, the histomorpholigical results of the lesions, as well as the clinical findings, laboratory and imaging studies, allowed us to formulate the primary testicular origin of tumor as burn out post-pubertal teratoma.As a result, in a young male patient who presented with a retroperitoneal mass or metastasis, a possibility of a germ cell neoplasia should be considered and testicular evaluation including physical examination and ultrasound of the scrotum and bilateral testis in the work-up is mandatory.


Fmr1 knock out (KO) mouse, also show auditory hypersensitivity, providing a translation relevant platform to study underlying pathophysiological mechanisms. The focus of this review is to summarize recent studies in the Fmr1 KO mouse that identified neural correlates of auditory hypersensitivity. We review results of electroencephalography (EEG) recordings in the Fmr1 KO mice and highlight EEG phenotypes that are remarkably similar to EEG findings in humans with FXS. The EEG phenotypes associated with the loss of FMRP include enhanced resting EEG gamma band power, reduced cross frequency coupling, reduced sound-evoked synchrony of neural responses at gamma band frequencies, increased event-related potential amplitudes, reduced habituation of neural responses and increased non-phase locked power. In addition, we highlight the postnatal period when the EEG phenotypes develop and show a strong association of the phenotypes with enhanced matrix-metalloproteinase-9 (MMP-9) activity, abnormal development of parvalbumin (PV)-expressing inhibitory interneurons and reduced formation of specialized extracellular matrix structures called perineuronal nets (PNNs). Finally, we discuss how dysfunctions of inhibitory PV interneurons may contribute to cortical hyperexcitability and EEG abnormalities observed in FXS. Taken together, the studies reviewed here indicate that EEG recordings can be utilized in both pre-clinical studies and clinical trials, while at the same time, used to identify cellular and circuit mechanisms of dysfunction in FXS. New therapeutic approaches that reduce MMP-9 activity and restore functions of PV interneurons may succeed in reducing FXS sensory symptoms. Future studies should examine long-lasting benefits of developmental vs. adult interventions on sensory phenotypes.The mechanisms underlying the common association between autism spectrum disorders (ASD) and sensory processing disorders (SPD) are unclear, and treatment options to reduce atypical sensory processing are limited. Fragile X Syndrome (FXS) is a leading genetic cause of intellectual disability and ASD behaviors. As in most children with ASD, atypical sensory processing is a common symptom in FXS, frequently manifesting as sensory hypersensitivity. Auditory hypersensitivity is a highly debilitating condition in FXS that may lead to language delays, social anxiety and ritualized repetitive behaviors. Animal models of FXS, including  There is a strong association between autism spectrum disorders (ASD) and sensory processing disorders (SPD). Indeed, the latest diagnostic criteria for ASD includes atypical sensory function as a core deficit. Research findings in both humans with ASD and animal models of ASD suggest that abnormal sensory processing in early development may lead to a broader array of symptoms including abnormal anxiety, social, and hyperactive behaviors –5. DespiFMR1 gene  mouse, show auditory hypersensitivity. Neural circuits involved in auditory processing, particularly those in the early stages of processing, are likely to be more conserved across humans and rodents than circuits involved in social and cognitive symptoms. There are many similarities between humans and rodents in the basic organization of the auditory system from subcortical areas to the primary auditory cortex. There is also a rich history of studying auditory system development. Given that FXS is a neurodevelopmental disorder, existing knowledge on normal auditory circuit development provides a strong basis to study circuits that underlie hypersensitivity. The auditory system and auditory-related symptomatology offer a translation-relevant platform to identify clinically-relevant phenotypes and study circuit mechanisms of deficits in FXS. Indeed, as reviewed below, studies of auditory cortical processing in humans with FXS and mouse models have found remarkable similarities across species.Both humans with FXS, and a commonly used animal model of the condition, the Many of the early studies of auditory hypersensitivity in humans with FXS focused on auditory event-related potential (ERP) recordings. ERP studies consistently showed enhanced amplitude of various components . Enhanced synchrony of population responses to individual tones is likely responsible for enlarged N1 component of ERPs observed in humans with FXS –20, whicn = 21, mean age = 26.4, range 10–55 yrs) exhibited greater gamma frequency band power (30–80 Hz) in the resting state EEG compared to age matched controls (n = 21). There was a reduction in alpha-gamma amplitude coupling across electrodes in FXS that suggests reduced top-down cortico-cortical control in FXS  and showed that abnormalities in gamma power were related to more severe behavioral and psychiatric features and reductions in neurocognitive functions. In addition, test-retest data shows reliability of measures in a third group of humans with FXS   . Taken tAlthough elevated gamma power is found consistently, additional studies are needed to address its relevance. For example, Wilkinson and Nelson  found elThe gamma power related to local network excitation may reduce the ability of the neural population to synchronize periodic gamma band activity. Indeed, Ethridge et al.  found spThe abnormal responses of auditory cortex to sound that are present from early development may affect communications and language skills , 36. IndFmr1 KO mice , 58Fmr1  KO mice  comparedckground , 55. In kgrounds , 59, sugmovement , suggestmulation . This ph KO mice . The incFmr1 KO rat model of FXS, which displayed enhanced baseline gamma band power, reduced alpha power and behavioral hyperactivity  in the EEG phenotypes and the specific frequency bands affected is remarkable, and could prove critically useful in developing similar outcome measures between pre-clinical and clinical trials, while at the same time facilitate discovery of underlying cellular and circuit mechanisms, and new therapeutic interventions in the animal models. Future studies need to validate selected EEG phenotypes as biomarkers by performing studies on robustness, scalability, tolerance to settings and equipment and sensitivity to drug treatments.Similar EEG phenotypes were also observed in the activity . In addick train . Interesng state . The higin vivo and in vitro approaches. Rotschafer and Razak  window during which cortical responses began to diverge in the auditory cortex of Fmr1 KO mice. Single unit recordings showed that responses were similar in cortical neurons of WT and Fmr1 KO mice at P14. However, the responses were larger in the Fmr1 KO cortex at P21. This indicates that just after hearing onset (~P10) in mice, the abnormal development of circuits induced by auditory experience may underlie cortical hypersensitivity in the Fmr1 KO mice. The Fmr1 KO rat visual cortex, as well, shows a divergence of responses around the period of eye-opening  was normal. These data indicate that a mixture of local cortical processing deficits and inherited deficits from subcortical sites lead to the observed cortical phenotypes, pointing to the need for a balanced investigation across the auditory neuraxis. Indeed, very little is known about subcortical auditory responses in humans with FXS. Interestingly, hyperactive locomotor behavior, but no changes in anxiety-like behaviors, was observed in mice with forebrain excitatory-specific Fmr1 deletion, pointing to combined cortical and subcortical contributions to behavioral deficits in FXS.While the brainstem and midbrain studies suggest that cortical hyperexcitability may reflect subcortical abnormalities, i et al.  found the et al.  examinedFmr1 KO mice in both visual and somatosensory systems -expressing interneurons. In particular, PV inhibitory interneurons in the cortex have been implicated in sensory hypersensitivity and abnormal sensory processing in  systems –79. Gibs systems  found a  systems –82. Thes systems , 84. A c systems . PNNs ar systems  and ther systems –89.Fmr1 KO mice . MMP-9 is a zinc-dependent endopeptidase that is found in many cell types, including neurons and glia  without causing any sedation or effects on baseline EEG power. Taken together, these data indicate that sound-evoked EEG responses may be more sensitive measures, compared to resting EEG measures, to isolate drug effects from placebo in humans with FXS. Minocycline or other MMP-9 inhibitors show much promise in reducing sensory issues in FXS and selecting sensitive outcome measures based on the mouse EEG data may prove useful in designing statistically powerful clinical trials.In addition to the improvements in mouse behaviors, a 10-day treatment of adult enotypes . By testy et al.  tested ak et al.  showed tFmr1 KO mice in a sound-attenuated environment did not reduce abnormal phenotypes, and in some cases exacerbated the symptoms  individual cortical neurons are hyper-responsive to sounds , 60; (2)Loss of FMRP → Increased MMP-9 → Reduced PNNs around PV cells → Reduced excitability of PV cells → Reduced inhibition of cortical networks → Abnormal gamma synchrony and cortical hyperexcitability.The functional deficits in sensory processing may emerge during specific developmental windows due to abnormal changes in circuit development providing an opportunity to target specific circuits for treatments during these windows . Given tFmr1 KO mouse model providing a possible link between over-activated mGluR5 and enhanced protein translation in neurons lacking FMRP  which likely originate in the midbrain/brainstem region , 110 canThe ability of early sound exposure, but not sound attenuation, to reduce cortical hyperexcitability symptoms suggests that developmental trajectories of atypical sensory processing need to be investigated across closely spaced developmental ages. Examination of deficits at a single age or a small number of ages may miss the main cause of pathology early on, and only record manifestation of compensatory mechanisms , 33, whiFmr1 KO mice in a prefrontal cortex dependent task (The excitement around developments in the field of gene therapy indicates this approach may allow re-expression of FMRP in the near future , 115. Hoent task . Despiteent task –119. TheKR, DB, and IE contributed to the writing of the review. All authors contributed to the article and approved the submitted version.This work was supported by the National Institute of Child Health and Human Development and the National Institute of Mental Health, U.S. Army Medical Research and Materiel Command and FRAXA Research Foundation.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Coronary cameral fistulas (CCFs) are rare congenital malformations consisting of abnormal vascular connections between coronary arteries and cardiac chambers, often incidentally found during cardiac catheterizations.A 66-year-old female asymptomatic patient, without cardiovascular risk factors and a history of varicose veins lower extremities and coronavirus disease 2019 (COVID-19) pneumonia in December 2020, was diagnosed by coronary angiography with two large coronary cameral fistulas connecting the distal right coronary artery (RCA) and the distal left circumflex artery (LCx) to the right ventricle (RV). Additional imaging modalities such as two-dimensional transthoracic/transesophageal echocardiography and three-dimensional multidetector CT angiography were required to confirm the fistula's pathway , which was difficult to delineate using selective coronary angiography alone. After heart team discussion, with the aim to reduce the risk of embolization, an innovative stent-assisted coil occlusion antegrade technique was used with optimal immediate results.Even though our otherwise asymptomatic patient was not the best suitable candidate for an interventional procedure , the innovative stent-assisted fistula coil occlusion technique to stabilize the first coil and deploy safely the additional ones resulted to be key for successful and complete obliteration of the abnormal congenital vascular connections. Coronary cameral fistulas (CCFs) are abnormal vascular connections between coronary arteries and cardiac chambers, reported to be found in ~0.09–0.5% of unselected patients undergoing diagnostic coronary angiography . These f2), significant compression of the right ventricular cavity by a thin-wall round-shaped chamber resulting in dislocation of the tricuspid valve structures toward the ventricular septum with marked tricuspid flow reduction  pneumonia in December 2020 underwent a clinical evaluation for an unexplained heart murmur. She was in New York Heart Association class I and her physical examination was negative except for grade II/VI non-radiating continuous murmur, louder in diastole, in the fourth intercostal space, and visible varicose veins in the lower limbs with skin pigmentation. Electrocardiogram showed right bundle branch block and chest X-ray revealed signs of mildly increased pulmonary flow and right chambers dilatation. Two-dimensional (2D) transthoracic/transesophageal Echocardiography (TTE/TEE) color Doppler demonstrated preserved left ventricular ejection fraction, mild mitral regurgitation, RV overload (end-diastolic diameter of 3.2 cm), tricuspid annular plane systolic excursion (TAPSE) of 2.1 cm, slightly enlarged right atrium  confirmed the presence of severely dilated and tortuous distal RCA and LCx  and precvia a direct arterial approach with a new stent-assisted coil occlusion technique to avoid the risk of embolization. The RCA was cannulated using a 6-Fr Judkins Right 4 guiding catheter and a 0.014 in Fielder guidewire (Abbott Vascular) was advanced distally and over it, a Medtronic Resolute Onyx™ DES 5 × 15 mm (Medtronic)was placed in the target point (third segment of RCA); concomitantly, a Cook Mreye (r) Flipper coil 40 × 5 mm through 6-Fr multipurpose catheter with stylet inside was placed distally to Onyx™ stent not taking out the stylet from the Flipper to prevent coiling. Then, the balloon of the stent was inflated and the stylet was pulled out from the Mreye (r) Flipper system, getting the system more stable and preventing the stent deformation. The Flipper coil was fixed to the arterial wall, the balloon of the stent deflated and taken out and finally, the coil was pushed ahead and detached. Due to the persistent coronary blood flow across the first implanted coil, two additional 8 cm × 5 mm Gianturco coils were deployed proximally to the Flipper coil achieving complete occlusion of the fistula without compromising the flow in coronary side branches  tend to be particularly torturous, presenting a challenge for antegrade transcatheter closure due to the rigidity of the delivery system through the tortuous coronary arteries. Furthermore, there may be multiple feeding arteries to a single drainage point and multiple exit sites may exist, like in this case.Obliteration by epicardial and endocardial ligations has been the standard surgical treatment , generalSuitable candidates for interventional procedures are patients with proximal, easily accessible non-tortuous fistula origin provided there is a single narrow draining site that can be safely accessible. Various methods for closure have been used such as coils, detachable balloons, duct occluders, vascular plugs, covered stents, polyvinyl alcohol foam, and histoacryl resin –15.Our case is unusual for many reasons. Firstly, the asymptomatic patient presented without cardiac or valvular anomalies other than the CCFs. Secondly, multiple imaging modalities were required to confirm the fistula's pathway, which was difficult to delineate using selective coronary angiography alone. Thirdly, the anatomy of those CCFs  was not suitable for transcatheter closure making coil occlusion at very high risk of embolization. Furthermore, this case of stent-assisted coil occlusion technique to stabilize the first coil was key for success and might broaden the scope of management of large CCFs, which were previously not suitable for device closure.Coronary cameral fistulas (CCFs) are rare congenital clinical entities, often incidentally found during coronary angiography. The diagnosis can be challenging requiring multiple imaging modalities. The innovative transcatheter stent-assisted coil occlusion technique has been key for successful antegrade closure of those uncommon coronary cameral fistulas, avoiding the risk of coils migration within the coronary artery branches.The original contributions presented in the study are included in the article/Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.This article was the original work of the authors who have all seen and approved of the paper and authorship. The article has not been published elsewhere and is not under consideration in any other journals.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Congenital clefts cause compromised function and esthetics, inadvertently affecting a patient’s social and mental health. These defects can be successfully managed by a multidisciplinary team that can provide holistic care from birth till adulthood and beyond. A 17-year-old girl with left side congenital cleft, who had undergone cleft surgeries at our center, reported with a chief complaint of a missing front tooth in the upper region. Clinical and radiographic investigations showed a need for tertiary grafting, which was done using an autologous iliac graft. After six months, a dental implant was placed and immediately loaded after implant stability quotient assessment. Treatment of cleft patients is arduous and technique sensitive and should be done following pre-defined protocols. Each case should be handled by a multidisciplinary team giving attention to each aspect of the treatment requirement. It is an added advantage if the treatment is holistically catered at a single center as it provides patient comfort and avoids patient dependence on past records. Congenital orofacial clefts affect one in 500-2,500 newborns globally ,2, havinThis case report was previously presented as faculty scientific paper presentation at the 49th Indian Prosthodontic Society National Virtual Conference 2021 on December 1, 2021, and won the best paper of the session award.A 17-year-old female visited our center with a chief complaint of a disfigured nose and missing tooth in the upper front region. The patient desired a fixed replacement as the missing tooth caused her psychological distress and esthetic insecurity.Born in June 2002 with a complete unilateral left-sided cleft involving the lip, alveolus, and hard and soft palate Figures , 1B, theAt six-and-a-half years of age in 2009, the patient revisited the center for secondary alveolar bone grafting (SABG), which later allowed eruption of permanent maxillary canine in the cleft region. In 10 years period till 17 years of age, orthodontic treatment without cleft-related surgical interventions was done by which best possible occlusion was achieved; however, the malformed tooth did not allow adequate space closure between the left central incisor and canine. At 17 years of age, rhinoplasty was done in May 2019 to address the chief complaint of the disfigured nose, which also reduced episodes of nasal congestion faced by the patient Figures , 1J.Clinical and radiographic assessments done after six months confirmed the presence of malformed permanent left lateral incisor with external root resorption, making it non-salvageable. It also showed inadequate bone for dental implant thus requiring tertiary alveolar grafting. At 18.5 years of age in December 2020, tertiary grafting was done using a combination of autogenous corticocancellous anterior iliac bone graft and platelet-rich fibrin. Cortical perforation of the recipient site was performed followed by graft beveling and adaptation, which was stabilized using titanium screws Figure . The defA 4.0 x 1 2 mm titanium dental implant  was placed in grafted site at an insertion torque of 30 Ncm. Primary implant stability quotient (ISQ) was assessed using Penguin RFA device , which showed a value of 74 Figure , thus enThree months after immediate loading, the temporary prosthesis was replaced with a screw-retained definitive porcelain-fused-to-metal crown Figure . Before The patient was successfully rehabilitated using a dental implant, which was immediately loaded thus decreasing treatment time. This significantly improved patient’s esthetics and helped address her chief complaints Figures -3F. The India sees numerous congenital cleft cases with a comparatively smaller number of comprehensive care centers. Each case is a unique presentation and requires sequential treatment for prediction of outcomes and potential complications, providing scope for modifications. A lack of a universal treatment approach was found by de Ladeira and Alonso who highlighted the absence of evidence-based surgical cleft treatment . RepairiCurrent cleft treatment strategies are focused on infant orthopedics, post-operative pain relief, cleft maxillary hypoplasia, perioperative steroids, and alveoloplasty with no mention of dental rehabilitation . With reCleft patients commonly develop mistrust and confusion due to a lack of guidance and knowledge about appropriate places for their treatment . PresentThe case highlighted the importance of sequential treatment and the success of an immediately loaded dental implant in the cleft site. The authors propose undertaking trials involving dental implant-based rehabilitation of cleft patients and their immediate loading where possible. We also propose setting of multidisciplinary centers in regions where they are currently non-existent so that sequential treatment can be provided to patients along with meticulous record-keeping and longitudinal patient follow-up so that cleft care is not limited to urban localities but is also extended to interior geographical locations where the population is largely unaware.


Asfarviridae is a group of nucleo-cytoplasmic large DNA viruses (NCLDVs) of which African swine fever virus (ASFV) is well-characterized. Recently the discovery of several Asfarviridae members other than ASFV has suggested that this family represents a diverse and cosmopolitan group of viruses, but the genomics and distribution of this family have not been studied in detail. To this end we analyzed five complete genomes and 35 metagenome-assembled genomes (MAGs) of viruses from this family to shed light on their evolutionary relationships and environmental distribution. The Asfarvirus MAGs derive from diverse marine, freshwater, and terrestrial habitats, underscoring the broad environmental distribution of this family. We present phylogenetic analyses using conserved marker genes and whole-genome comparison of pairwise average amino acid identity (AAI) values, revealing a high level of genomic divergence across disparate Asfarviruses. Further, we found that Asfarviridae genomes encode genes with diverse predicted metabolic roles and detectable sequence homology to proteins in bacteria, archaea, and eukaryotes, highlighting the genomic chimerism that is a salient feature of NCLDV. Our read mapping from Tara oceans metagenomic data also revealed that three Asfarviridae MAGs were present in multiple marine samples, indicating that they are widespread in the ocean. In one of these MAGs we identified four marker genes with > 95% AAI to genes sequenced from a virus that infects the dinoflagellate Heterocapsa circularisquama (HcDNAV). This suggests a potential host for this MAG, which would thereby represent a reference genome of a dinoflagellate-infecting giant virus. Together, these results show that Asfarviridae are ubiquitous, comprise similar sequence divergence as other NCLDV families, and include several members that are widespread in the ocean and potentially infect ecologically important protists.The family  Nucleocytoviricota, comprise a phylum of dsDNA viruses that infect diverse eukaryotes , also called karyotes . NCLDVs karyotes . Some farecently . Althougrecently . Given tAsfarviridae is a family of NCLDVs for which the most well-studied member is the African swine fever virus (ASFV), an emerging pathogen that was first discovered in 1921  was cultivated, and partial sequencing of the DNA polymerase type B and MutS genes revealed that the virus likely belonged to the Asfarviridae  shared between all genomes analyzed in this study using the Proteinortho tool version 6.0.14  with defhttps://github.com/faylward/lastp_aai. This script uses LAST to detect bi-directional best hits to find the pairwise identity of orthologous proteins  using the python script available at proteins . The resproteins  in the RIn order to assess the sequence similarity, the raw metagenomic reads from TARA ocean samples described previously  were dowPoxviridae as an outgroup. We used five marker genes: major capsid protein (MCP), superfamily II helicase (SFII), virus-like transcription factor (VLTF3), DNA Polymerase B (PolB), and packaging ATPase (A32), that are previously shown to be useful and used for phylogenetic analysis of NCLDV MAGs (github.com/faylward/ncldv_markersearch), also previously described  contained a PolB sequence with > 98% AAI to the PolB sequenced from the s HcDNAV  (as asceThe Asfarvirus MAG assembly sizes ranged from 120 kbp (SRX802982.1) to 580.8 kbp (GVMAG-S-3300009702-144). Among the 35 MAGs, 17 had all five core genes used for phylogenetic analysis  while the rest of the genomes were missing only one core gene, including three MAGs in which the highly conserved PolB marker was not identified. This suggests that the MAGs are generally high quality, although the absence of some marker genes suggests that some are only nearly complete and that MAG assembly sizes are underestimates of the complete genome sizes. The % G+C content for the new MAGs ranged from 17 to 60%, while those of reference viruses ranged from 31 to 45%. The ARAGORN software predicted three tRNA genes  for ERX552270.16, one Ile-tRNA gene for GVMAG-M-3300013133-40, GVMAG-M-3300023174-161, GVMAG-M-3300027793-10, GVMAG-S-3300005056-23, and GVMAG-S-3300010160-169, and one Arg-tRNA gene for SRX319065.14. One tRNA gene (Ile) was also predicted in reference virus – Pacmanvirus as described previously . The comTo assess the phylogenetic diversity and evolutionary relationships of the new MAGs, we constructed a phylogenetic tree based on alignment of the five conserved marker genes. These marker genes have been previously described to be highly conserved in the NCLDVs . The phyAsfarviridae , while 37 proteins had best hits to Asfarvirus genomes in this database . Togetherviridae , but it rviridae . For purAsfarviridae.In addition to phylogenetic analysis, we also performed pairwise AAI analysis to assess the genomic divergence between different Asfarviruses. Our analysis recovered pairwise AAI values ranging from 27 to 75%  with meaAsfarviridae family, which is consistent with the high level of variability in other families of NCLDV , ubiquitin dependent protein-ubiquitin ligases were found to be expressed within 5 min of virus-infection and is thought to be involved in degradation of host proteins  proteins in 21 out of 35 MAGs . NifS geGene encoding for cell redox homeostasis (KOG0191) and cellular response to nitrogen starvation (KOG1654) were also common among the MAGs. Nutrient limitation has the potential to reduce viral productivity; virus reproduction mostly depends upon the intracellular nitrogen and phosphorous pool during early infection while they might depend upon the extracellular nitrogen availability as infection proceeds . Genes iWhile ASFV is a terrestrial pathogen and most cultured Asfarviruses were isolated from sewage samples, various metagenomic studies have revealed that NCLDVs are highly diverse and abundant in aquatic environments , and oneHeterocapsa circularisquama, which is responsible for harmful algal blooms in the marine environment (Asfarviridae that confirmed that these viruses cluster closely together (Heterocapsa circularisquama or a closely related dinoflagellate. Given these similarities, ERX552270.16 may be a useful reference genome for exploring the genomics and distribution of close relatives of HcDNAV, though further work will be necessary to confirm the host of ERX552270.16.Previous studies have shown that the virus HcDNAV infects the marine dinoflagellate ironment . This isironment . Althougironment . We founironment . The Polironment . Moreovetogether . Our fratogether , consistAsfarviridae for many years, recent work has identified numerous additional members of this viral family. In this study, we provide a robust phylogenetic and comparative genomic analysis of this viral family. Our results highlight the high level of genomic and phylogenetic divergence between disparate members of the Asfarviridae, and homology searches suggest that many genes within this viral group are potentially the product of ancient horizontal transfers from cellular lineages. Moreover, we provide fragment recruitment plots that confirm that some Asfarviruses are ubiquitous in the ocean, where they may infect ecologically important protists such as bloom forming dinoflagellates. These findings suggest that diverse Asfarviruses are broadly distributed in the environment and play important roles in numerous ecosystems.While ASFV was the only known member of https://www.ncbi.nlm.nih.gov/.Publicly available datasets were analyzed in this study. This data can be found here: FA designed the study. SK and MM performed the experiment. SK and FA wrote the manuscript. All authors contributed to the article and approved the submitted version.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.


Spinal cord ischemia leads to iatrogenic injury in multiple surgical fields, and the ability to immediately identify onset and anatomic origin of ischemia is critical to its management. Current clinical monitoring, however, does not directly measure spinal cord blood flow, resulting in poor sensitivity/specificity, delayed alerts, and delayed intervention. We have developed an epidural device employing diffuse correlation spectroscopy (DCS) to monitor spinal cord ischemia continuously at multiple positions. We investigate the ability of this device to localize spinal cord ischemia in a porcine model and validate DCS versus Laser Doppler Flowmetry (LDF). Specifically, we demonstrate continuous (>0.1Hz) spatially resolved (3 locations) monitoring of spinal cord blood flow in a purely ischemic model with an epidural DCS probe. Changes in blood flow measured by DCS and LDF were highly correlated (r = 0.83). Spinal cord blood flow measured by DCS caudal to aortic occlusion decreased 62%. This monitor demonstrated a sensitivity of 0.87 and specificity of 0.91 for detection of a 25% decrease in flow. This technology may enable early identification and critically important localization of spinal cord ischemia. Paralysis and paraparesis, resulting from iatrogenic spinal cord ischemia are not infrequent complications of vascular surgery for management of aortic disease –7, spineThe approaches most widely employed for intraoperative spinal cord ischemia monitoring are motor and somatosensory evoked potentials. Unfortunately, evoked potentials (EP) have high false positive and false negative rates , 22, andAn optimized spinal cord monitor would offer the ability to immediately detect and regionally/axially resolve the level of origin of the ischemia, independent of anatomic variability in vascular supply. Such qualities could speed surgical response and focus it toward restoring spinal cord blood flow. To address these limitations, here we demonstrate a novel optical device to measure spinal cord blood flow. To measure spinal blood flow, the device employs diffuse correlation spectroscopy (DCS) , 28 and DCS utilizes a diffusion model of light transport in tissue to provide rapid, quantitative, and non-invasive measurements of blood, as validated against several clinical techniques , 29, 30.The FLOXsp probe  is <0.13Correlator.com) and the resulting temporal autocorrelation function transmitted to a data acquisition and instrument control computer (PXIe-8135 in chassis PXIe-1082) with auxiliary instrument control (PXIe-6361), data-acquisition (PXIe-6612) and data-processing (PXI-7822R) cards . Here, data were fit in real-time to a solution of the correlation diffusion equation  % , while mean blood flow caudal to the occlusion dropped by -62 [–75–46] % from baseline . We calcCombining simultaneous measurements of blood flow changes at three axially-separated sites on the spinal cord, we developed a simple algorithm to localize the balloon inflation as ’above all’, ’between cephalad and central’, ’between central and caudal’, and ’below all’ detectors see . UtiliziTo test the ability of the device to detect and localize spinal cord ischemia we chose an approach that elicits ischemia without directly compressing the spinal cord. This was accomplished through use of an intra-aortic balloon which can be positioned and repositioned accurately using fluoroscopy between aortic occlusion (inflation) trials. Additionally, the probe is not disturbed during these periods of ischemia, minimizing potential motion artifacts due to the model. This approach also conveniently replicates aortic occlusion during open or endovascular thoraco-abdominal aortic repair.The ability to regionally discern the origin of spinal cord ischemia is particularly important in repair of the thoracoabdominal aorta where the impact of the extent of resection or endovascular graft coverage remains unpredictable due to a high degree of variability in native vascular supply to the spinal cord, and/or to variability in effects of prior disease , 41. It A shorter aortic balloon or greater spacing between the source-detector pairs on the FLOXsp probe would improve localization consistency at the expense of axial spatial resolution. Anatomical variation in the precise origin relative to the terminus of the small arteries supplying the spinal cord may provide a practical limit to the precision of axial resolution of ischemia.In the present work, our device has demonstrated its ability to spatially localize the level of aortic occlusion, potentially offering an improved opportunity for focused intervention.The anatomy of the porcine spinal cord is highly comparable to the human spinal cord  and this3) of superficial tissues (<2 mm from the surface), while the DCS technique as employed here is sensitive to a larger region (~ 5 cm3) up to ~10 mm into the tissue. Thus, comparison between the two methods is somewhat problematic as each samples a different tissue bed, likely partially explaining the discrepancy between techniques shown in Our study had several limitations. We choose to use LDF as a comparator technique as it provides a continuous blood flow metric in the operating room. However, the LDF technique typically uses very short source-detector separations  and is sensitive to a small region .(PDF)Click here for additional data file.


Variable disease progression confounds accurate prognosis in Fabry disease. Evidence supports the long-term benefit of early intervention with disease-specific therapy, but current guidelines recommend treatment initiation based on signs that may present too late to avoid irreversible organ damage. Findings from the ‘PRoposing Early Disease Indicators for Clinical Tracking in Fabry Disease’ (PREDICT-FD) initiative included expert consensus on 27 early indicators of disease progression in Fabry disease and on drivers of and barriers to treatment initiation in Fabry disease. Here, we compared the PREDICT-FD indicators with guidance from the European Fabry Working Group and various national guidelines to identify differences in signs supporting treatment initiation and how guidelines themselves might affect initiation. Finally, anonymized patient histories were reviewed by PREDICT-FD experts to determine whether PREDICT-FD indicators supported earlier treatment than existing guidance.Current guidelines generally aligned with PREDICT-FD on indicators of renal involvement, but most lacked specificity regarding cardiac indicators. The prognostic significance of neurological indicators such as white matter lesions (excluded by PREDICT-FD) was questioned in some guidelines and excluded from most. Some PREDICT-FD patient-reported signs  did not feature elsewhere. Key drivers of treatment initiation in PREDICT-FD were: (A) male sex, young age, and clinical findings , (B) improving clinical outcomes and preventing disease progression, and (C) a family history of Fabry disease . All guidelines aligned with (A) and several advocated therapy for asymptomatic male patients. There was scant evidence of (B) in current guidance: for example, no countries mandated ancillary symptomatic therapy, and no guidance advocated familial screening with (C) when diagnosis was confirmed. Barriers were misdiagnosis and a lack of biomarkers to inform timing of treatment. Review of patient histories generally found equal or greater support for treatment initiation with PREDICT-FD indicators than with other guidelines and revealed that the same case and guideline criteria often yielded different treatment recommendations.Wider adoption of PREDICT-FD indicators at a national level could promote earlier treatment in Fabry disease. Clearer, more concise guidance is needed to harmonize treatment initiation in Fabry disease internationally.The online version contains supplementary material available at 10.1186/s13023-022-02181-4. GLA gene encoding α-galactosidase A  can cause lysosomal α-Gal A deficiency and accumulation of globotriaosylceramide (Gb3) and globotriaosylsphingosine (LysoGb3) . On. On21]. The focus of PREDICT-FD was on indicators for FD-specific treatment initiation in patients who had already received a diagnosis of FD; however, the need for diagnosis  is stipulated before treatment in all guidelines reviewed ; Portugal and Slovenia ; Switzerland ; and the UK . Other countries recommend considering disease-specific therapy only when symptoms appear: Canada  ; France Statement 2. “Improving clinical outcomes and preventing disease progression are key drivers of early initiation of FD-specific treatment.”For other patient groups, Portugal also advocates treatment of any pediatric patient  who presents with certain signs . Guidance from Catalonia (Spain), Portugal, Slovenia, Switzerland, and the UK associates additional criteria with initiation in women and men with late-onset disease  covered the broadest set of cardiac indicators, and Canadian guidance provided specific criteria for most of these, notably those assessed by cMRI. All the reviewed national or regional guidelines included cardiac indicators, but most could have been defined more precisely or expanded to include other measures. Synthesis of detailed cardiac criteria for treatment initiation in FD may be possible from the various guidelines examined. Countries were mostly aligned on renal indicators, although attitudes to confirmatory renal biopsy varied. The value of such histological evidence is undisputed, but some countries exclude it whereas others recommend it in justifying disease-specific therapy. Most guidelines included metrics for patients with proteinuria, typically a manifestation of FD presenting later than some other renal indicators. However, retaining such indicators in guidance is useful to allow for delayed diagnosis. In terms of neurological signs, few countries considered white matter lesions to be supportive of treatment initiation, Canadian guidelines noting that their clinical significance in FD is unclear.Among the drivers of treatment initiation identified by PREDICT-FD, some could be more widely addressed in guidelines than currently. Early treatment initiation to optimize clinical outcomes requires early diagnosis of male patients with classical FD and careful follow-up of non-classical male and female patients for early clinical signs/symptoms of organ involvement as described in many guidelines. Studies in untreated symptomatic women with FD indicate that guidelines can be applied inconsistently in different patient groups , 30.The recommendation to treat early is based largely upon expert opinion, so it is important to collect more supportive research data. For example, there may be an optimal age for FD-specific treatment initiation in each patient group. It is likely that techniques such as cMRI and monitoring of biomarkers may not be widely accessible. In these cases, local guidelines could be amended to encourage prompt referral to a regional specialist center. Guidelines could also recommend screening relatives of individuals with a recent diagnosis of FD to try to identify asymptomatic cases requiring follow-up and possibly treatment.Two barriers to treatment initiation have a substantial impact on effective management of FD: lack of biomarkers and misdiagnosis. Tests for a small number of biomarkers are conducted in some centers but are not widely available, and their prognostic value for disease progression and/or treatment responsiveness remains unclear. LysoGb3 has been associated with negative clinical outcomes in FD , and treIn addition to considering drivers of and barriers to treatment initiation, the PREDICT-FD expert panel was asked to speculate about the possible impact of the initiative. The need for biomarker research echoed discussions of barriers to treatment and is clearly a source of frustration. However, should PREDICT-FD raise disease awareness, such research endeavors may follow, and findings relating to the timing of treatment initiation and cessation may translate into changes in clinical practice. Early treatment initiation has been the principal focus of PREDICT-FD and expansion of treatment criteria at the national level based on the consensus findings of PREDICT-FD could help to realize this. As well as the potential for improved patient outcomes, harmonizing treatment decisions facilitates consistent communication about such decisions among specialists, patients, and their primary care physicians.Given the differences among the guidelines reviewed, we undertook a preliminary investigation of how this might affect treatment decisions at the patient level. Expert panel members unanimously supported treatment initiation or continuation in nearly half of the cases reviewed, irrespective of which criteria formed the basis for assessment. Furthermore, in only three cases did applying different guidance cause a panel member to change their decision. Case histories were chosen to exemplify occasions when the decision to treat was equivocal based on country guidance and, in eight cases, different decisions about treatment initiation were reached based on the same criteria. Thus, ambiguity exists in clinical guidelines and emphasizes the utility of a more standardized approach. Increasing the granularity of criteria against which patients are assessed may help to address this. Pragmatism must also be exercised when devising guidance. Anecdotally, there were cases in which confirmatory renal biopsy had been conducted simply to satisfy the requirements of a guideline. This highlights how such invasive procedures can become a barrier to treatment.Our study has limitations. Comparison of the guideline criteria had to be qualitative because most indicators for treatment initiation were not described or measured uniformly across the guidelines. Comparative performance of case studies against the various guidelines could provide insights about specific differences that translate into treatment delays, but a more structured prospective approach with a larger sample size than used here would be needed. At a superficial level, most of the case histories considered were as likely or more likely to receive a positive treatment recommendation based on PREDICT-FD than on other criteria, but in all cases the sample size was very small. Also, all authors participated in the PREDICT-FD consensus initiative , which mWhen an FD diagnosis has been confirmed, disease-specific treatment should be offered as soon as possible to male patients with classical disease, and it should be considered at the earliest signs of organ involvement in other patient groups to try to stabilize or even to reverse disease progression. Although guidance is generally aligned on early indicators of renal involvement, the PREDICT-FD consensus identified several early signs of cardiac involvement not yet widely adopted; Canadian guidelines  could beDetails of the PREDICT-FD Delphi consensus methodology have been reported previously . BrieflyAfter the PREDICT-FD consensus initiative, panel members were asked to provide local guidelines for disease-specific therapy of FD. National FD treatment guidelines were supplied by panel members from Australia , Canada Additional file 1: Supplementary data.


Tetraspanin family of proteins participates in numerous fundamental signaling pathways involved in viral transmission, virus-specific immunity, and virus-mediated vesicular trafficking. Studies in the identification of novel therapeutic candidates and strategies to target West Nile virus, dengue and Zika viruses are highly warranted due to the failure in development of vaccines. Recent evidences have shown that the widely distributed tetraspanin proteins may provide a platform for the development of novel therapeutic approaches. In this review, we discuss the diversified and important functions of tetraspanins in exosome/extracellular vesicle biology, virus-host interactions, virus-mediated vesicular trafficking, modulation of immune mechanism(s), and their possible role(s) in host antiviral defense mechanism(s) through interactions with noncoding RNAs. We also highlight the role of tetraspanins in the development of novel therapeutics to target arthropod-borne flaviviral diseases. Flavivirus genus includes more than seventy small, positive-sense single-stranded RNA viruses transmitted by vectors, such as ticks and mosquitoes  in immune response-based therapies towards flaviviruses . AlthougDrosophila melanogaster, and 33 members in humans with characteristic features and orthologs in other distantly related species, such as insects and arthropods  and PROSITE (ExPASy) and are shown in (Tetraspanins are recognized to play significant role(s) in the pathology of infectious diseases caused by dengue, corona, hepatitis and influenza viruses . Tetraspthropods . The evothropods . Overallthropods . Structuthropods . Glycosyshown in . Tetraspshown in , 21. Tetshown in . Virusesshown in . Howevershown in . Recent shown in  and CD9 shown in , which eshown in . TEMs cashown in . They hashown in , 27.Among all the cell surface proteins, Cluster of Differentiation  and Tetraspanin (Tspan) types that includes Tspan7 and Tspan9 have been reported to be involved in viral infections . TEMS, stsp29Fb expression resulted in a substantial reduction in DENV2 loads in cells and significantly decreased export of the viral E-protein and RNA genome in exosomes ) are both potential therapeutics to block DENV2/3 and perhaps other mosquito-borne flaviviruses  and antiviral pathways against tick-borne viral infections , and antigen-presenting cells  as both of them distribute into the immune synapses . TetraspNoncoding RNAs (ncRNAs) molecules play a variety of functions such as siRNAs has been involved in antiviral defenses, miRNAs and piRNAs controls transposons and regulation of gene expression, and lncRNAs mainly implicated in modulation of immune response mechanism of flaviviruses . ExosomeIxodes scapularis tick miRNAs in viral replication including POWV  with RNA-binding proteins . RNA-bining POWV , and LGTing POWV . Our groing POWV . Currenting POWV . In addito cells . A studyto cells . These fMAGED1, STAT1, and IL12A genes that might play a key role as biomarkers for designing new strategies to prevent DHF  and have greater impact on viral biology . Arthropvent DHF . Transcrnfection . Collectin vitro, and anti-CD81 antibody administration have been shown to exhibit a protective role in vivo  due to their role in viral interactions. Strategies such as RNA interference (RNAi) and antibody-mediated blocking of tetraspanin proteins function could be developed as ideal approach to prevent viral infections. Treatment with antiviral drugs such as viral-cell receptor interaction inhibitors, interferon’s, and viral enzyme inhibitors could lead into significant reduction in the viral loads but these may not completely eradicate viruses . Additio in vivo . The imm in vivo .The palmitoylation of tetraspanin CD9 and CD151 plays a significant role in TEM assembly that could possibly suggests novel target for microbial infections . It has via recombinant exosomes (A. aegypti mosquitoes efficiently expressed a DENV-targeting single-chain variable fragment (scFv) derived from a previously characterized broadly neutralizing human antibody, which blocked the infection and transmission in these mosquitoes  to understand their full potential for therapeutics chassis a) how do arthropod tetraspanin(s) can be used as therapeutic targets for vaccine or antiviral drugs? b) How do ncRNAs interfere with tetraspanins in the modulation of immune responses and respective cellular mechanisms? c) How do three-dimensional structures of different tetraspanins appear? d) Could arthropod tetraspanins affect immune responses to flaviviruses and other microbes? e) What other putative viral co-receptors participate with arthropod tetraspanins to modulate the viral entry and release? f) Is it feasible to generate genetically modified vector such as mosquitoes or ticks lacking tetraspanin? In summary, detailed characterization of arthropod tetraspanin(s) will not only facilitate our understanding of pathogenicity of flaviviruses but also will lead to the development of novel effective therapeutic tools such as antiviral drugs and vaccines to combat vector-borne diseases.Tetraspanins also play a key role in the regulation of different cellular processes. RNAi-mediated repression of tetraspanin gene expression or antibody-mediated blocking of tetraspanins function could be employed as effective antiviral strategies to control infections. One of the other thoughts is will it be helpful to make knockout mosquitoes for different arthropod TSPs, and will it be feasible to free knockout or genetically modified mosquitoes lacking TSPs in the field. However, it is important to first delineate if these knockout mosquitoes will survive in nature without TSPs. Genetics and transgenetic are quite strong in mosquitoes when compared to ticks, however, there could be several challenges to make knockout mosquitoes. RNAi-mediated silencing of mosquito Tsp29Fb (a human ortholog of CD63) significantly reduced DENV2 loads in both mosquitoes and the infectious EVs derived from these cells. We did not observe any morphological or viability issues with the All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.Research in this area is supported by R01 AI141790 grant award to HS from National Institute of Health (NIH)/National Institute of Allergy and Infectious Diseases (NIAID).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.


Acute pulmonary embolism and severe renal bleeding are two lethal postoperative complications, but there has been no report that involves both of them after mini-percutaneous nephrolithotomy.A 62-year-old woman was admitted to our hospital with extremely severe hydronephrosis and multiple right renal calculi. After thorough examination, she received prone-position mini-percutaneous nephrolithotomy under spinal anaesthesia. Three days postoperatively, the patient complained of chest pain and dyspnea. Computed tomography pulmonary angiogram (CTPA) showed multiple embolisms in the left pulmonary artery and its branches. Symptoms were relieved after anticoagulant and thrombolysis therapy. On the 6th postoperative day, the patient developed shortness of breath, computed tomography angiography (CTA) showed massive hemorrhage in the right kidney, diffused contrast medium in the middle and lower part of the right kidney was seen during digital substraction angiography (DSA). Superselective right renal artery embolization (SRAE) was then applied using coil to occlude the responsible artery. The patient generally recovered under conscientious care and was approved to be discharged 26 days postoperatively.This is the first case that involved both acute pulmonary embolism and severe post thrombolysis renal bleeding. The importance of D-dimer in the prediction and early detection of pulmonary embolism should be noted. For post thrombolysis renal bleeding, SRAE is considered as a reliable treatment. Percutaneous nephrolithotomy (PCNL) is a common treatment for large upper urinary tract calculi with the advantage of both high stone-free rate and efficiency. The main postoperative complications of PCNL are bleeding, infection and organ damage . Since iA 62-year-old woman came to our center with extremely severe hydronephrosis and multiple right renal calculi found by annual physical check. She reported no renal colic, nausea or fever and had no current use of any medications. Her temperature was 36.7 °C, pulse 89 bpm, respiratory rate 18 bpm, and non-invasive blood pressure 130/57 mmHg. Unenhanced CT scan demonstrated extremely severe hydronephrosis and multiple right renal calculi with the largest diameter of 2 cm  at once and offered emergency CTPA, which revealed multiple embolisms in her left pulmonary artery and its branches  for further life-supporting therapy. In order to prevent venous thromboembolism (VTE), 0.4 ml LMWH was subcutaneously injected every 12 h in ICU. Routine re-examination of the lower limbs venous ultrasonography and echocardiography was ordered to monitor the patient’s condition. Sonographers reported the remission trend of tricuspid regurgitation and pulmonary hypertension. Intermuscular venous thrombosis in her left leg could no longer be detected 6 days after the thrombolysis treatment.On the 6th postoperative day, the patient suddenly developed unconsciousness and anhelation in ICU, and her blood oxygen saturation progressively dropped to 85%. Urgent intubation, mechanical ventilation and blood transfusion were applied to correct the patient’s anemia. Gradually, her oxygen saturation rose to 98%, but crimson and opaque drainage fluid kept flowing through her nephrostomy tube without any sign to stop even after clamping the catheter for 30 min. Her hemoglobin (Hb) level was still decreasing progressively Fig. . SRAE waPulmonary embolism (PE) is a type of VTE. It is a relatively rare but life-threatening complication for patients undergoing PCNL: The dense distribution of blood vessels in the operating field, intraoperative vascular wall injury, and the increase in bed rest time might all contribute to the rising incidence of post-PCNL PE . The preIn terms of thromboprophylaxis, EAU2020 guidelines  recommenIn this case, the elevation of D-dimer (570 ng/ml) 2 days after the surgery drew our attention, so we informed the attendants to massage the lower limbs of the patient to prevent thrombosis, and dynamically re-examined the D-dimer. In our daily practice, D-dimer was re-examined the first day after surgery, and patients with elevated D-dimer (> 500) were offered with ultrasound of the lower extremity vein. A previous study  demonstrAlthough D-dimer has an ideal sensitivity in the diagnosis of PE, its specificity varies. Renal function abnormality is common in patients with urinary calculi, but a previous study has shown that the specificity of D-dimer to rule out PE decreases with declining renal function . Thus, wAccording to the 2019 edition of ESC-APE guidelines, anticoagulant therapy is the primary treatment for acute pulmonary embolism, while thrombolysis therapy may ameliorate pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR) and RV dilatation by promoting the dissolution of blood clots in high-risk patients with hemodynamic changes . A meta-For those patients who completed percutaneous nephrolithotomy, surgical field bleeding after thrombolysis is considered nearly inevitable. We believed that early thrombolysis and accurate hemostasis of the relevant vessels might shorten the recovery time, reduce blood loss and lower the risk of hemorrhagic shock. The color of urine and Hb level are vital signs that might contribute to the early diagnosis of post thrombolysis bleeding. To the best of our knowledge, progressive bleeding can be preliminarily judged by the drainage fluid and the level of Hb: The appearance of the drainage fluid in the nephrostomy tube is crimson and opaque even after clamping the tube for a while; The level of Hb keep decreasing progressively. For patients with those signs, DSA could help to make the diagnosis and directly block the injured vessels by SRAE. It could precisely locate and reliably embolize the injured vessels to control bleeding while minimizing the influence of systemic coagulation function. For those who failed to stop bleeding after one SRAE treatment, repeated SRAE is still an effective backup plan. The result of a retrospective study involving 49 patients who underwent SRAE found no significant decrease in renal function during the 6–64month follow-up compared with preoperative examinations . For patTo sum up, for patients who develop PE after percutaneous nephrolithotomy, early diagnosis, prompt anticoagulation therapy and appropriate thrombolysis are necessary. Since post-thrombolysis bleeding is nearly inevitable for patients who underwent PCNL, close monitoring of post-thrombolysis bleeding is vital to minimize blood loss and prevent hemorrhagic shock. To the best of our knowledge, immediate SRAE might be the ideal treatment for its adequate hemostatic ability with scanty impact on renal function. More importantly, urologists should be cautious in surgical decision-making, especially for patients with a solitary kidney or renal insufficiency. Although mini-PCNL could achieve less bleeding compared with conventional PCNL, strategic staging retrograde intrarenal surgery might be an alternative for better safety.


Peripheral nerve tissues possess the ability to regenerate within artificial nerve scaffolds, however, despite the advance of biomaterials that support nerve regeneration, the functional nerve recovery remains unsatisfactory. Importantly, the incorporation of two-dimensional nanomaterials has shown to significantly improve the therapeutic effect of conventional nerve scaffolds. In this review, we examine whether two-dimensional nanomaterials facilitate angiogenesis and thereby promote peripheral nerve regeneration. First, we summarize the major events occurring after peripheral nerve injury. Second, we discuss that the application of two-dimensional nanomaterials for peripheral nerve regeneration strategies by facilitating the formation of new vessels. Then, we analyze the mechanism that the newly-formed capillaries directionally and metabolically support neuronal regeneration. Finally, we prospect that the two-dimensional nanomaterials should be a potential solution to long range peripheral nerve defect. To further enhance the therapeutic effects of two-dimensional nanomaterial, strategies which help remedy the energy deficiency after peripheral nerve injury could be a viable solution. Two-dimensional (2D) nanomaterials have received great interest by the whole research community due to their exceptional electrochemical properties, based on the special character of atom-scale thickness, which allows for the free transfer of electrons on the material surface. Furthermore, 2D nanomaterials exhibit enhanced and tunable electronic, physical and chemical properties due to their distinctive phase, crystallinity, degree of exfoliation, stability and fundamental limitation of thickness . In addiIn this review, we summarize the applications of 2D nanomaterials in aiding PNR and focus on the mechanism of new-vessel guided regeneration. First, we summarize the major physiological events occurring after PNI. Second, we describe the application of 2D nanomaterials in peripheral nerve engineering and the corresponding therapeutic effects. Third, we analyze the mechanism by that the newly-formed capillaries provide directionality and metabolic support for neural regeneration. Finally, we discuss the use of 2D nanomaterial-based neural regeneration devices as a potential biomedical strategy to improve long range peripheral nerve defects, and how that could help to remedy the energy deficiency after PNI.The peripheral nerve acts as a real-time information transmitter between human brain and the rest body. Compared to the well-protected brain and spinal cord in the central nervous system by the skull and vertebrates, peripheral nerves are not surrounded by hard structures, making them extremely vulnerable to different physical damage. Normally, PNIs result in numbness, locomotor dysfunction and even life-long disabilities for individuals , causingThe peripheral nervous system (PNS) is among the very few tissues in adult mammals which possess remarkable regeneration capabilities after injury. After PNI, Schwann cells–the myelin forming cells in the PNS–dedifferentiate and transform into a repair phenotype that play key roles in the nerve regeneration process . HoweverPNIs are characterized by the retraction of two nerve stumps or the direct loss of a nerve segment. During the regeneration process, a natural bridge forms between the two nerve stumps  where daIn this subsection, we update the applications of 2D nanomaterials for the fabrication of nerve scaffolds, and focus on the mechanism that the 2D nanomaterials could facilitate the formation of new blood-vessels and discuss their pro-regenerative effects for PNR .2 hybridization, provides graphene with outstanding electrical conductivity, surface area and mechanical properties  protein expression within the graphene-based scaffold was higher when compared to the autograft transplantation 18 months after PNI. Interestingly, the robustly formed capillaries provide the regenerating axons with a microenvironment rich in nutrients. The cell soma of peripheral axons resides in spinal cords and DRGs, so we dissected the spinal cords and DRGs of the rats implanted with graphene-based scaffolds 18 months after injury. We found that the expression level of nestin, a protein specifically expressed in neural stem cells that plays essential roles in neural stem cell differentiation, were upregulated. These results indicate that the presence of graphene accelerates axonal regrowth by creating a pro-angiogenesis microenvironment and increase the stemness of neurons. Interestingly, the high VEGF concentration within the graphene scaffold chamber is also responsible for the increased neuronal activity after PNI. The receptors of VEGF are not only expressed on endothelial cells but also present on the axons and growth cones. The conditional knockdown of hypoxia-inducible factor 1a (HIF-1a) in mice DRG leads to impaired neuronal regenerative ability and the local administration of VEGF could partly remedy this  /myeloid differentiation factor 88 (MyD88)/nuclear factor kappa-B (NF-κB) pathway, thereby excrete VEGF  . The exce models . One posete VEGF . The humBack in the 1990s, researchers started to observe the relevance between capillary number and nerve regeneration outcomes. Hobson et al. visualized the interactions between RECA-1 positive endothelial cells, S100 positive Schwann cells and axons at different time points after PNI . They foHow does the endothelial cells respond to the nerve injury? In intact nerve tissues, blood vessels go along with nerve fascicles and supply oxygen and nutrients to maintain the normal physiology of nerve function. However, after traumatic nerve injury, both the nerves and the accompanied blood vessels are severely damaged and eventually completely transected causing a hypoxic microenvironment within the injured site. 2 days after nerve dissection, the injury site undergoes severe hypoxia . InteresWhat is the cellular mechanism behind the blood vessel guided nerve regeneration? Schwann cells, a key cell type that plays a major role in the orchestration of PNR, get attracted by the vessel bridge . The SchWhere are the newly formed vessels from? Cattin et al. suggested that the new vessels originate from both the proximal and distal nerve stumps, whereas Hobson et al. pointed out that new vessels originate from the adjacent muscle beds . The difIn summary, newly formed vessel is the premise for successful PNR. The capillaries directly guide Schwann cell migration and indirectly contribute to axonal regeneration. The ability of angiogenesis modulation should be taken into account when designing a neural regeneration device .It remains an open question whether 2D nanomaterials facilitate micro-vessel formation and guidance to migrating Schwann cells. In this subsection, we propose a new mechanism which suggests that the newly-formed capillaries may provide nutrients necessary for the proliferation Schwann cells, and metabolically support neuronal regeneration.2D Nanomaterials Facilitate Micro-Vessel Formation and Provide Guidance for Migrating Schwann Cells, the newly formed blood vessel is the premise for neural regeneration in PNS where the capillaries serve as tracks for Schwann cells to migrate along and indirectly guide axonal regeneration (Tissue regeneration is a highly energy-demanding process and energy deficiency happens during PNR as well . In respneration . It remaneration . The GLUneration . Thus, tneration .via Schwann cells. However, the 2D nanomaterial itself potentially harms the cellular metabolism, while the incorporation of a bio-metabolic active substrate could remedy this and further enhance the therapeutic effects of 2D nanomaterials.Therefore, apart from angiogenesis, attention should also be paid upon the metabolic process during PNR. However, several studies pointed out that the 2D nanomaterials pose threat on endothelial cells by disturbing the metabolic pathways. In this regard, Chen et al. performed transcriptional sequencing on 2D black phosphorus exposed aortic artery and identified metabolic disturbance . Furthervia electric stimulation, but also facilitate angiogenesis within the regenerating nerve tissue, which directly stimulates Schwann cell proliferation and enhance axonal outgrowth. In this review, we summarize the updates on the mechanism underlying this phenomenon and point out that the 2D nanomaterial promotes PNR via facilitating angiogenesis.Artificial nerve scaffolds hold great promise for the biomedical treatment of injured nerves by connecting the damaged stumps and new nerve tissues form within the scaffold chamber . Howeverin situ? Whether the protein within the regeneration microenvironment envelop the 2D nanomaterials to form the “protein corona” and whether the protein-adsorbed nanomaterials change their original biological activities (Despite there are strong evidences to support that 2D nanomaterials modulate the angiogenesis ability to aid PNR, there are still questions to be answered. What is the target cell of 2D nanomaterials? Whether the 2D nanomaterials directly interact with endothelial cells to drive the proliferation and capillary-forming responses? Or macrophages internalize the 2D nanomaterials to initiate the HIF-1α/VEGF signaling axis, and thereby attract endothelial cell migration? Whether the 2D nanomaterials need to be released from the scaffold to facilitate angiogenesis, or do they take effect tivities ?Moreover, the concentration of 2D nanomaterials should be taken into consideration when fabricating artificial nerve scaffolds. Many nanostructures can facilitate angiogenesis when administered at low dose, but at high dose, they will inhibit new vessel formation . This biAlthough researchers developed various neural regeneration devices to treat PNI, long-range nerve defect remains a huge challenge . The posApart from angiogenesis, emphasis should also be placed upon the metabolic disturbance after peripheral nerve injury. Recent studies revealed the metabolically regulatory effects of certain biomaterials and the bioenergetic-active materials substantially accelerated tissue regeneration . Thus, tPNIs result in over 8.5 million restricted activity days and almost five million bed or disability days per year. In the US alone, over 200,000 peripheral nerve repair procedures are performed annually . So ther