To illustrate the association between the sociodemographic characteristics of hospital markets and the geographic patterns of Medicare hospital value‐based purchasing (HVBP) scores.This is a secondary analysis of United States hospitals with a HVBP Total Performance Score (TPS) for 2019 in the Centers for Medicare and Medicaid Services (CMS) Hospital Compare database (4/2021 release) and American Community Survey (ACS) data for 2015–2019.This is a cross‐sectional study using spatial multivariable autoregressive models with HVBP TPS and component domain scores as dependent variables and hospital market demographics as the independent variables.We calculated hospital market demographics using ZIP code level data from the ACS, weighted the 2019 CMS inpatient Hospital Service Area file.ß = −12.79, p < 0.0001), followed by the percent of the population coded to “non‐Hispanic, some other race” , and the percent of families in poverty . Percent of the population was non‐Hispanic American Indian/Alaskan Native  and percent non‐Hispanic Asian  were associated with higher TPS. Lower predicted TPS was observed in large urban cities throughout the US as well as in states throughout the Southeastern US. Similar geographic patterns were observed for the predicted Patient Safety, Person and Community Engagement, and Efficiency and Cost Reduction domain scores but are not for predicted Clinical Outcomes scores.Spatial autoregressive models using eight nearest neighbors with diversity index, race and ethnicity distribution, families in poverty, unemployment, and lack of health insurance among residents ages 19–64 years provided the best model fit. Diversity index had the highest statistically significant contribution to lower TPS (The lower predicted scores seen in cities and in the Southeastern region potentially reflect an inherent—that is, structural—association between market sociodemographics and HVBP scores. Medicare's hospital value‐based purchasing program scores have been shown to be lower for safety‐net hospitals, resulting in reduced Medicare reimbursement.There has been a call to adjust the scores for the socioeconomic status of patients seen by each hospital, but regulators have resisted holding these hospitals to a lower standard.The local and regional geographic impact of these policies across the United States has not been explored.We created maps showing how the hospital scores were potentially affected by the sociodemographic characteristics of their market areas.Hospitals in the Southeastern states and larger cities with racial and ethnic diversity had lower predicted scores, potentially representing an increased risk of lower hospital value‐based purchasing program scores.Patient experience, patient safety, and hospitalization related costs contributed to the lower predicted scores. There was less evidence of regional geographic patterns in clinical quality.1The Centers for Medicare and Medicaid Services (CMS) implemented hospital value‐based purchasing (HVBP) for acute care hospitals starting with 2012 discharges as part of the Affordable Care Act.Numerous commentators have noted that as the US payer system moves toward pay‐for‐performance/value‐based purchasing, there is a risk of increased penalization of safety‐net hospitals.While the association between safety‐net hospital status and lower overall performance on HVBP has been explored in a growing body of literature, the extent and patterns of the impact of the racial and socioeconomic make‐up of patient populations on HVBP scores across the US have not been explored from a geospatial perspective. Our objective is to apply spatial data analysis to map the association between hospital markets and HVBP scores across the US, illustrating both local detail and broader regional trends. Our work fits into the public health tradition of disease mapping wherein the local nature of spatial patterning of data is explicitly used to improve estimation.22.1n = 2673).This is a cross‐sectional observational study of all non‐federal general medical/surgical hospitals in the United States (US) receiving scores for 2019 discharges in the CMS HVBP program, as of the April 1, 2021 release  models to each dependent variable to estimate the predicted scores based on individual hospital's independent variables and the observed scores of neighboring hospitals. These spatial models account for the spatial dependence between observations . These models are more conservative and less biased than ordinary least squares (OLSs) regression models, particularly given the spatial dependency  in hospital markets.k) matrix for each hospital was created for each hospital for k = 6–10 neighbors per hospital. Imputation was used to assign missing values for the HVBP domain scores, which were missing for a small number of hospitals, which allowed the same neighbor matrix to be used for all models.A formal model selection process was used to determine the appropriate form of the multivariable spatial regression. A nearest‐neighbor . Each candidate model was then applied to the test data, and the final model was selected that had the most candidate variables without loss‐of‐fit, for example, where the mean squared error leveled off. The variables in this final model were then used to fit a SAR model on the entire data set for TPS. We compared the SAR model using k = 6–10, and the k with the best model fit using the Akaike information criterion was used for all subsequent models. For consistency, the same model was used for the HVBP component scores.We used a backward elimination process to select the independent variables used in the analysis. We split the data into training (70%) and test (30%) data sets and fit OLS regression models to the training data with TPS as the outcome measure, beginning with the full set of variables listed above and removing the variable with the lowest k‐neighbors.Because the predictors in SAR models include both the modeled variables and the dependent variables for the k‐nearest neighbors, the interpretation of the estimated coefficients is not as straightforward as for OLSs, although the direction and magnitude of the coefficients retain their interpretive properties.k‐neighbor) patterns of the independent variables.We created dot maps of the observed and predicted HVBP scores to allow comparison of regional patterns. Maps of the predicted values from SAR models show the influence of smoothing the dependent variables based on the local  had HVBP TPS and data on ZIP codes of their Medicare fee‐for‐service patients on the CMS service area file.3.1The selected model included 11 variables , which can be due to outliers in the predicted HVBP scores or to the presence of regional patterns in addition to the modeled local patterns.Of the included variables, racial/ethnic diversity had the strongest association by a large margin, although it did not reach statistical significance in the model for clinical outcomes. Once adjusted for diversity, the other race and ethnicity categories tend to have positive, albeit weaker, associations with the HVBP outcomes, indicating hospitals serving communities with higher concentrations of residents of specific racial or ethnic groups tended to perform slightly better. For example, the five hospitals with markets that were 75% or more non‐Hispanic AIAN had a low diversity index , but a high observed TPS . Three of these facilities were Indian Health Service hospitals, and the other two were tribal hospitals.3.2There is clear spatial patterning to the predicted TPS that is not as evident in the observed scores Figure . Regionaß coefficients for the sociodemographic variables in the models that generated these estimates. On the other hand, many urban areas had higher predicted Clinical Outcomes Scores.Similar spatial patterning was observed for the predicted Person and Community Engagement Score, predicted Safety Score, and predicted Efficiency and Cost Reduction Scores Figure . While t4We used spatial autoregression to predict HVBP scores based on the sociodemographic composition of each hospital's market. Our principal result is that accounting for the sociodemographic composition of hospital markets on HVBP TPS results in increased risk of low scores in large urban cities as well as in the Southeastern United States. When the individual domains of the HVBP scores are examined, the Person and Community Engagement, Safety, and Efficiency and Cost Reduction domains reflect the same regional and urban patterns. Clinical outcomes, on the other hand, show clustering of higher predicted scores in large urban areas. Our results complement the recent report by Khullar et al., who reported that the US Census Bureau’ South Atlantic and East South Central regions and counties with a higher proportion Black residents had a disproportionate proportion of hospitals that were low‐performing across all three CMS value‐based programs.Of all the sociodemographic variables examined, the US Census Bureau's diversity index had the strongest association in the SAR models. This reflects the idea that areas with higher percentages of racial and ethnic diversity tended to have lower‐performing hospitals, regardless of what specific racial or ethnic minority group predominated. While many studies of inequality in access to quality health care concentrate on the lower availability of health care, there is a growing body of literature reporting on the association between hospital quality and minority‐service hospital status across multiple health states and conditions.Multiple commentators have suggested that pay‐for‐performance measures and publicly reported star ratings should be adjusted for neighborhood or patient demographic characteristics.As a cross‐sectional ecological study, we need to be careful not to over‐interpret these findings. Translating these findings into a causal relationship between HVBP incentive payments and poorer quality care received by individuals, particularly in specific demographic groups or regions, is beyond the scope of this study.5Wider understanding of potential structural racism in access to higher quality care is hindered by the lack of nationwide data on quality‐of‐care data stratified by patient demographics at the hospital or community level. Researchers interested in the demographic geography of the hospital service areas have generally been limited to defining service areas based on the physical location of the hospital, ranging in scale from block group or census tractUse of the Medicare fee‐for‐service population may misestimate hospital service areas in areas where (1) there is heterogeneity in market share by patient age and (2) there is local geographic heterogeneity in the adoption of Medicare Advantage adoption. Our calculation of market demographics also assumes that hospital choice by residents of a specific ZIP code does not vary by the demographic factors examined. Previous studies have shown this assumption is likely violated; White patients are more likely to travel further for care.6Our findings highlight the potential for structural racism in the HVBP program, with lower predicted scores for hospitals in the Southeastern states and larger cities in the US that have higher levels of racial and ethnic diversity. In particular, we show a consistent finding for a spatial relationship between market sociodemographic composition and the HVBP Person and Community Engagement and Efficiency and Cost Reduction domains, both of which have been shown in previous studies to be associated with hospital patient mix. We also show this spatial patterning for the safety domain, which has not been as well documented. This exploratory study complements existing understanding of place‐based structural racism on value‐based payment metrics and further highlights the need for re‐evaluation of policy regarding adjustment of incentive payments to reduce disparities among hospitals that serve minority populations.


The development of new approaches indirectly measuring the structural disconnectome has recently led to an increase in studies investigating pairwise structural disconnections following brain damage. Previous studies jointly analyzed patients with left hemispheric and patients with right hemispheric lesions when investigating a behavior of interest. An alternative approach would be to perform analyses separated by hemisphere, which has been applied in only a minority of studies to date. The present simulation study investigated whether joint or separate analyses  are appropriate to reveal the ground truth disconnections. In fact, both approaches resulted in very different patterns of disconnection. In contrast to analyses separated by hemisphere, joint analyses introduced a bias to the disadvantage of intra‐hemispheric disconnections. Intra‐hemispheric disconnections were statistically underpowered in the joint analysis and thus surpassed the significance threshold with more difficulty compared to inter‐hemispheric disconnections. This statistical imbalance was also shown by a greater number of significant inter‐hemispheric than significant intra‐hemispheric disconnections. This bias from joint analyses is based on mechanisms similar to those underlying the “partial injury problem.” We therefore conclude that pairwise structural disconnections in patients with unilateral left hemispheric and with unilateral right hemispheric lesions exhibiting a specific behavior (or disorder) of interest should be studied separately by hemisphere rather than in a joint analysis. We simulated pairwise structural disconnections and compared two approaches of analyzing brain damage: unilateral lesions from both hemispheres together or separated by hemisphere. In contrast to the separate analyses, the joint analysis led to biased results: intra‐hemispheric disconnections were statistically underpowered and therefore missed more often compared to inter‐hemispheric disconnections. The latter are available only from specific diffusion weighted imaging sequences such as Diffusion Tensor Imaging (DTI), which are only sparsely available for most clinical cases. Software packages such as the Lesion Quantification Toolkit  via custom scripting. We conducted two simulation paradigms, for which we defined three pairwise ground truth connections: one inter‐hemispheric connection and one intra‐hemispheric connection in each hemisphere , we set the disconnection of the three ground truths to 0. For the critical cases , we pseudo‐randomly generated a disconnection score between 30 and 100  for either the inter‐ or the intra‐hemispheric connection. Scores for the critical ground truth inter‐hemispheric and intra‐hemispheric connections were identical to ensure equal prerequisites , we utilized mass‐univariate pairwise analyses based on online available scripts . Contrary to Simulation 1, the disconnection scores differed to some degree between hemisphere and type of connection in the less controlled Simulation 2 . In contrast, when separating the analyses according to hemisphere, damage to both ground truth connections of each hemisphere, that is, the inter‐hemispheric as well as the intra‐hemispheric connection, was significantly linked to the simulated behavior  directly simulated or (ii) estimated indirectly from simulated unilateral left and unilateral right hemispheric lesions. We observed that joint and separate analyses resulted in very different patterns of disconnection. Analyses separated by hemisphere showed a more realistic image with respect to the simulated connection‐behavior association of the respective inter‐ or intra‐hemispheric ground truth connections.In the joint analysis of left and right hemispheric lesions, intra‐hemispheric disconnections were statistically underpowered and thus surpassed the significance threshold with more difficulty compared to inter‐hemispheric disconnections. In contrast, analyses separated by hemisphere did not neglect one type of disconnection. Our first, pairwise disconnection‐based simulation, which represents a scenario of perfect circumstances, clearly preferred the approach of analyzing both hemispheres separately, because only this approach could detect all ground truth connections. This finding indicates that the procedure of separate analyses is methodologically seen the undisputedly best approach. Our second simulation, which represents the noisier but more natural scenario, showed similar effects. Different from our first simulation, with increasing noise, the separate analyses as well as the joint analysis could not detect all ground truth connections. However, this issue is more of a general problem resulting from lower effect sizes due to insufficient sample sizes. Our simulation revealed that—at the same noise level—an increased sample size led to the detection of all underlying ground truth connections in the separate analysis approach, whereas the statistical bias was still preserved in the joint analysis. Our data thus suggest that—depending on different effect sizes, sample sizes, and background noise of the respective data set—the sole application of analyses separated by hemisphere can already be sufficient, while in other cases, separate analyses might not catch all ground truth disconnections because of the statistical threshold used and the insufficiently large effect size of the missed disconnection. However, increasing the sample size might eliminate this issue as shown by the present simulation. Also, reporting the uncorrected results might be an option to deal with small sample sizes.In a recent article of our group, we conducted both a joint analysis of unilateral left and right hemispheric patients as well as individual analyses separated by hemisphere on real data of stroke patients suffering from “pusher syndrome”  because such a disconnection could only be caused by part of the sample. Third, even if one merges homologous left‐sided and right‐sided intra‐hemispheric connections in the connectivity matrix together to solve the issue of statistical imbalance in the joint analysis, results would not be reliable as the assumption of homologous structural connections sharing also homologous functions cannot be considered as universally valid in studies dealing with cognitive functions in the human brain.Sperber et al.  concludeSince the systematic bias induced by the joint analysis is a consequence of the sampling rather than the applied statistical approach, it would also persist in multivariate approaches and Bayesian frameworks, which are known to alleviate some issues associated with univariate approaches and frequentist statistics, respectively. In the joint analysis, inter‐hemispheric disconnections would receive larger Bayes factors than intra‐hemispheric disconnections, reflecting the same mechanisms described in the present simulation using t‐statistics. Moreover, the present conclusions retrieved from pairwise structural disconnection‐deficit‐associations by unilateral brain lesions, such as strokes or tumors, are very likely to also apply to tract‐wise disconnection measures, which define the damage not based on disconnected region‐pairs but on the disconnected white matter fiber tracts. Tracts, like region pai, can be characterized as inter‐hemispheric (when the tract passes through both hemispheres) or intra‐hemispheric (when the tract remains within one hemisphere) and are therefore likely susceptible to the same statistical bias we found here for pairwise measures. However, future studies should verify this assumption.5The results derived from the present simulation study on pairwise structural disconnection analyses indicate that jointly analyzing unilateral left and unilateral right hemispheric lesions leads to a methodological bias, whereas the approach of individual analyses separated by hemisphere represents the accurate way to deal with such data sets. Joint analyses systematically underestimate possibly existing intra‐hemispheric disconnections, which might therefore be considered less relevant or even completely missed. In contrast, the approach of hemispheric separation avoids such biased results. Hence, we propose that analyses separated by hemisphere should be considered as standard for pairwise (and tract‐wise) structural disconnection studies.The authors report no competing interests.Figure S1. Overlap of the 240 simulated lesions. Voxel‐wise overlap of the simulated lesions (N = 120 per hemisphere) is shown for the whole sample (top row), critical target lesions (middle row), and “control” lesions (bottom row) on the ch2‐template in MNI space via MRIcron (https://www.nitrc.org/projects/mricron). Lesions were randomly generated for the left and right hemisphere separately. The color bar indicates the number of overlapping lesions for each voxel. Numbers above each column represent the z‐coordinate (mm) in MNI space. All lesions of the 50‐sample (see main manuscript) are also included in the 120‐sample.Figure S2. Effects of joint and separate analysis approaches on pairwise disconnections induced by 240 simulated lesions. Results were obtained from the lesion‐based simulation for 120 lesions per hemisphere after permutation‐based correction for multiple testing and are visualized for the joint analysis  and analyses separated by hemisphere across different noise levels . (A) For each pairwise ground truth connection, t‐statistics are visualized. The dashed line represents the corrected significance threshold across the noise levels; t‐statistics displayed above the line represent results significant at p < .05.  (B) Numbers of inter‐ and intra‐hemispheric disconnections surpassing the significance threshold (p < .05) are depicted. (C) The pattern of pairwise disconnections significant at p < .05 is shown in the anterior view exemplary for the 75% noise level.Click here for additional data file.


The aim is to perform a model‐based cost‐effectiveness analysis of a silver diamine fluoride (SDF) protocol intervention to divert dental general anaesthesia (DGA) among Victorian children aged 2–10 years.Data inputs were based on an Australian single‐cohort 2017/18 study. Intervention costs for standard care were derived from two subgroups of children: (1) children who received standard care without DGA, and (2) children who received standard care with DGA. Two scenarios were modelled due to limited post‐follow‐up data: (1) children receiving SDF had standard care without DGA (base‐case scenario), and (2) children receiving SDF did not receive standard care without DGA . A simple decision‐tree model with probabilistic sensitivity analysis (PSA) estimated the incremental costs per diverted DGA.The probability of children requiring specialist referral and offered SDF, but the primary carer opted for DGA is 0.124 (SD 0.034), and the probability of children requiring DGA in standard care is 0.346 (SD 0.036). For both the base‐case and alternative scenario, the incremental cost‐effectiveness ratio outcome is dominant and their cost‐effectiveness being either 74.8% or 100% respectively.The SDF protocol intervention is cost‐effective dental caries management option for young children where referral for DGA is considered. © 2022 Australian Dental Association. ADAAustralian Dental AssociationDGAdental general anaesthesiaDWAUdental weighted activity unitECCearly childhood cariesNCDsnon‐communicable chronic diseasesPPHspotentially preventable hospitalizationsPSAprobabilistic sensitivity analysisSDFsilver diamine fluorideEarly childhood caries (ECC) is one of the most prevalent and preventable non‐communicable chronic diseases (NCDs), with a global estimate of 48% .Preservation of the primary dentition is essential to a child's well‐being and development.The burden on the healthcare system due to untreated ECC and dental caries among children is significant. Over 90% of potentially preventable hospitalizations (PPHs) for children aged 0–4 years and 5–9 years in Victoria, Australia, had the principal diagnosis of dental caries.ECC management can be impractical on dental chair, largely due to the limitations of patient co‐operation.Regular application of SDF has demonstrated the potential in arresting dental caries.While evidence demonstrating the effectiveness of the SDF has been well documented, its cost‐effectiveness and implications for the use of SDF protocol intervention in practice remain unknown. The economic benefit of the SDF can inform investment decisions for resource prioritization. Therefore, the specific aim of this study is to perform a cost‐effectiveness analysis (CEA), from the healthcare perspective, of the SDF protocol intervention for Victorian children aged 2–10 years compared to standard care to divert DGA.This model‐based CEA utilized information extracted from a published Victorian‐based SDF protocol intervention paper and a dental services audit from the Royal Dental Hospital Melbourne (RDHM). The details of the recruitment and outcome are published elsewhere Fig. .37 TheThe costs of the SDF protocol intervention were not collected in the study. So, treatment costs were derived from a multiplication of Dental Weighted Activity Unit (DWUA) of each item codes and the cost allocation of AUD$439.65 per DWUA. The item codes were retrieved from the dental services audit, and matched according to the Australian Dental Association dental item code descriptions.Based on the published SDF protocol intervention study, 33 children required a second session of the SDF protocol at the 6‐month follow‐up due to residual active dental caries, and two children required referral for DGA.Treatment costs of the standard care were estimated from an analysis of dental services provided for children aged 2–10 years old who were referred to the paediatric department at RDHM in 2018. Dental records in 2018 were selected to avoid the disruption in service delivery during the Covid‐19 restrictions to dental services during 2020–2022. Two subgroups of children aged 2–10 years old were used to inform the costs for standard care. The first cohort were children who were referred to RDHM received ‘usual care’ dental treatment without DGA. Of this group, the probability of children who were put on the DGA waiting list was identified and assumed to received DGA within 1 year. The second cohort was children who received DGA at the RDHM in 2018. Costs of dental treatments for standard care were estimated using the similar approach for SDF protocol intervention.Statistical analysis was performed using Stata IC Version 12 (Statacorp™). Treatment costs were reported in Australian dollars in 2018 price. Given time horizon of the model is 1 year, discounting was not applied. Extrapolation of the effectiveness was not attempted due to limited information of treatment consequences beyond 1 year.A simple decision‐tree model was constructed for the CEA in Fig.  using TrProbabilistic sensitivity analysis (PSA) was performed using Monte Carlo simulation with 1000 cycles to simulate 1000 trials by using random sampling of the parameter inputs for each variable distribution. This is illustrated in the cost‐effectiveness plane Fig. , which iThis cost‐effectiveness study was reviewed and obtained ethics approval from [removed for blind peer review].The mean costs for the first session of the SDF protocol intervention are AUD$190.81 and the mean costs for the second session of the SDF protocol intervention are AUD$131.24 (cost variation is based on less active carious lesions requiring reapplication of SDF). The profile of dental services under the standard care is presented in Table The parameters inputs for the decision‐tree model are reported in Table Under the base case scenario, the economic evaluation resulted in a mean cost‐saving of AUD$171.01  per child and had a mean effectiveness of 0.298  of diverted DGA, for 1 year. The alternative scenario yielded a mean cost‐saving of AUD$518.50  per child and had a mean effectiveness of 0.300  of diverted DGA.The 1000 plausible incremental costs per diverted DGA values are illustrated on the ICER plane Fig.  and meanThe dominant outcome when the ICER value was calculated in our study demonstrates the SDF protocol intervention saved costs and it was more effective to divert DGA compared to standard care. The yielded cost‐savings are consistent with previous research from a US simulation study demonstrating the potential cost‐savings would range between US$100 to US$350 per restorative visit,The study outcome is not surprising given there is strong evidence for the clinical effectiveness of the application of SDF for arresting dental caries.Whilst not explicitly considered in the Australian SDF protocol intervention study,More regular dental appointments via the SDF protocol intervention are consistent with the US study, where children who received SDF applications according to the American Academy of Pediatric Dentistry (AAPD) guidelines,Given the intervention is cost‐saving and more effective to divert DGA, the broader adoption of the SDF protocol intervention would release healthcare resources. This can hasten access to oral healthcare for children where the use of SDF would have negligible impact on DGA outcomes such as acute dental trauma or established symptomatic carious lesions including pain, swelling and active dental infections (abscess). Alternatively, the freed resources can be redirected to fund and provide other healthcare services. Greater impact for minimizing expenditure on healthcare resources would occur for the SDF protocol intervention if it were to be implemented in routine practice at the local Victorian community dental agency, except where dental extractions indicated. Lastly, any outcome to divert DGA would minimize the risk of mortality, which is estimated to be 3 per 1 million persons for dental treatment under DGA.The results of this economic evaluation should be interpreted with caution given the data inputs were not derived from a randomized controlled trial, the time horizon is a short duration (1 year), and the sample size included children up to 10 years old. It is possible that children who received the SDF protocol intervention may only delay their inevitable dental caries management trajectory towards DGA after 1 year. Another limitation related to the cost component is the unknown direct dental treatment costs for the SDF protocol intervention prior to the referral to RDHM and any subsequent costs after the 6‐month follow‐up. A longer follow‐up period is needed to determine whether the underestimate of the dental treatment costs for the SDF protocol intervention would significantly affect the probability for cost‐effectiveness.Other cost considerations not included in this CEA are the potential cost consequences external to the health service sector, that is, the societal perspective. Standard care provided under DGA can minimize the opportunity costs lost by the primary carer due to taking time off work and the travel costs to and from the dental clinic. These societal costs could be higher for SDF protocol intervention given the greater likelihood to attend multiple appointments for review and re‐application of SDF. The exclusion of the societal costs may influence the CEA results. At an individual level, the societal costs could vary dramatically, that is, primary carers of children living in rural and remote areas, where regular access to preventive services is scarce, may opt for DGA if they cannot accept the societal costs.Our CEA study provides evidence to strengthen the statement regarding the use of SDF by the Australian fluoride guidelines to promote its broader adoption amongst dental practitioners. The SDF protocol intervention is cost‐effective with high degree of certainty. It is recommended that the SDF protocol intervention is the preferred option advocated by dental practitioners where referral for DGA is considered for dental caries management. Future research should explore the potential longer‐term consequences for incorporating the SDF protocol intervention over a longer‐time horizon, and whether its cost‐effectiveness is maintainable.Deakin University Human Research Ethics Committee (ID 2021‐431).


The introduction of magnetic resonance (MR) linear accelerators (MR‐Linac) marks the beginning of a new era in radiotherapy. MR‐Linac systems are currently being operated by teams of radiation therapists (RTs), radiation oncology medical physicists (ROMPs) and radiation oncologists (ROs) due to the diverse and complex tasks required to deliver treatment. This is resource‐intensive and logistically challenging. RT‐led service delivery at the treatment console is paramount to simplify the process and make the best use of this technology for suitable patients with commonly treated anatomical sites. This article will discuss the experiences of our department in developing and implementing an RT‐led workflow on the 1.5 T MR‐Linac. This work provided an overview of processes involved in the development of an RT‐led workflow for the adapt‐to‐position (ATP) approach on the 1.5 T MR‐Linac. Magnetic resonance (MR) imaging has been shown to provide valuable additional information for many tumour sites and associated normal tissues due to its excellent soft tissue discrimination and functional information.The traditional radiotherapy treatment planning process may span between days to weeks with the exception of ‘plan and treat’ cases where the planning workflow may be reduced to hours. By contrast, the process of MRgART condenses the planning workflow into minutes at the treatment console. As a result, the process requires input from the multidisciplinary radiation oncology professionals; radiation therapists (RTs), radiation oncology medical physicists (ROMPs) and radiation oncologists (ROs) at the treatment console. This is resource‐intensive and logistically challenging,This work aimed at providing an overview of processes involved in the development of an RT‐led approach to MRgART on the 1.5 T MR‐Linac.The concept of MRgART allows treatment plan adaptation for every fraction with options of multiple adaptation methods. There are two workflows available when treating on the Unity MR‐Linac : adapt‐to‐shape (ATS) and adapt‐to‐position (ATP) using Monaco treatment planning system (Elekta AB). The ATSMultidisciplinary team meetings involving RTs, ROs and ROMPs were held to identify the appropriate tumour site and cases suitable for the RT‐led workflow. It was decided that intact prostate cancer patients receiving more than five fractions would benefit from the RT‐led workflow, as prostate cancer is the most common clinical indication for treatment on MR‐Linac in our centre.The ATS workflow is used for the first five fractions of every patient. This ultimately creates a library of patient‐specific data sets and plans that can be utilised for the RT‐led ATP workflow. The steps involved in the ATS workflow are highlighted in Figure Once the library of datasets and plans has been created from the first five fractions, the RT‐led ATP workflow can be used from fraction 6 without the RO present. The steps involved in the RT‐led workflow are displayed in Figure Respiratory and organ motion contribute to geometrical uncertainty in radiotherapy, and longer time on the radiotherapy couch may be associated with larger uncertainties. Therefore, due to the adaptive nature of each fraction, it is essential that critical online decisions are made swiftly and consistently. This required close multidisciplinary teamwork to define and optimise treatment workflows and thresholds for decision‐making and action levels. Strict tolerance and action levels were developed for the RT‐led workflow Table . A decisA credentialing framework was developed for this workflow using the experience of another Elekta Unity site  through personal communication, as well as the input from internal ROs and RTs. This credentialing programme enabled those RTs working on the MR‐Linac to be trained and competent in the RT‐led workflow in an online setting. The credentialing consists of both offline and online components to be completed by RTs. In the offline component, the RTs are required to prepare 20 MRgART plans using the RT‐led workflow; then, these are reviewed by a qualified RO. Once these 20 plans are signed off and deemed clinically acceptable, the RTs are required to complete 10 plans online using the RT‐led workflow under the supervision of the prescribing RO. The credentialing framework covers appropriate reference plan choice, image registration, identification of the anterior wall of rectum, bladder volume assessment and the understanding of the decision tree and when to engage the RO.The RT‐led adaptive workflow for prostate cancer using MR‐Linac has been successfully implemented at St Vincent's Hospital, Sydney, GenesisCare. Since the initiation of this workflow, eight RTs have been successfully credentialed. The RT‐led workflow has broadened the responsibilities of RTs and allowed for role expansions since the implementation of this approach. We found that the implementation of this workflow has reduced the overall treatment times by 10 to 15 min and relieved ROs from being at the console for all fractions. The time saved could be attributed to the seamless workflow performed by RTs alone as opposed to having multiple work groups performing various tasks.Online tasks required as part of MRgART increase the workload of key radiotherapy staff. With an increasing number of patients being treated on MR‐Linac systems, the transition of tasks from ROs to RTs is being widely investigated. A recent study reported that the general consensus from focus group interviews of RTs, ROs and ROMPs was to move towards RT‐led workflows.We anticipate the current working model of MR‐Linac systems will continue to evolve as RT‐led treatment becomes more prevalent in routine practice and new anatomical sites or clinical indications are introduced. Artificial intelligence may also be integrated into this process as it becomes applicable to the workflow. Moving forward, roles and responsibilities may cross traditional boundaries, to enable a prompt and less resource‐intensive MRgART.The implementation of an RT‐led workflow for prostate cancer using MR‐Linac has presented a number of benefits including efficiency gained through a seamless treatment delivery process, broadening RTs' skillsets and role expansions. The development of the RT‐led workflow required close collaboration between RTs, ROMPs and ROs. This workflow has provided a framework to expand the process to other tumour sites.The author declares no conflict of interest.


Impatiens species  along an elevational gradient in the Gaoligong Mountains of southwest China and estimated SDS using mean dormancy percentage of fresh seeds germinated at three constant temperatures . We downloaded 19 bioclimatic variables from WorldClim v.2.1 for each Impatiens population and used internal transcribed spacer (ITS), atpB‐rbcL, and trnL‐F molecular sequences from the GenBank nucleotide database to construct a phylogenetic tree of the 11 species of Impatiens. Logistic regression model analysis was performed to quantify the effects of phylogeny and environment on SDS. Results identified a significant phylogenetic SDS signal in the Impatiens species. Furthermore, elevation and phylogeny accounted for 63.629% of the total variation in SDS among the Impatiens populations. The best logistic model indicated that temperature was the main factor influencing variation in SDS among the Impatiens species, and model residuals were significantly correlated with phylogeny, but not with elevation. Our results indicated that seed dormancy is phylogenetically conserved, and climate drives elevational patterns of SDS variation in mountain ecosystems. This study provides new insights into the response of seed plant diversity to climate change.Seed dormancy contributes greatly to successful establishment and community stability and shows large variation over a continuous status scale in mountain ecosystems. Although empirical studies have shown that seed dormancy status (SDS) is shaped by elevation and phylogenetic history in mountain ecosystems, few studies have quantified their combined effects on SDS. Here, we collected mature seeds from 51 populations of 11  This manuscript reveals that seed dormancy is an ecological adaptation strategy and is phylogenetically conserved that provides new insights into the response of seed plant diversity to climate change. HoweverSaxifraga longifolia (Saxifragaceae) from high elevations show the highest proportion of dormant seeds  seeds collected from high‐elevation habitats show more complex SDS than seeds from low‐elevation habitats, requiring more periods of cold stratification to break dormancy  are threatened by climate warming due to compromised seed dormancy release  species  populations varies from 0 to 1 under different ambient temperatures , while identifying genuine sources of SDS variation in elevational patterns  Are there significant phylogenetic signals of SDS in Impatiens species? (2) How much of the SDS variation in Impatiens can be explained by both phylogeny and elevation? (3) After controlling for climatic factors, are the relationships between SDS and phylogeny and elevation still significant?Environmental selection is the basic driving force of seed trait evolution  are characterized by a huge elevational range and extremely high levels of biodiversity  coordinates of population provenance were also recorded using a handheld GPS device. The provenance localities were at elevations ranging from 1292 to 3840 m a.s.l., covering much of the elevational range of the genus  despite suitable environmental conditions. Most fresh seeds are in a state of dormancy at maturity  at three constant temperatures  and regularly watered with distilled water  .Nineteen global bioclimatic layers  have been shown to be valuable in phylogenetic studies within Balsaminaceae . The three sequence alignments were subsequently concatenated into a single alignment using Geneious v.9.1. Based on the concatenated alignment, a phylogenetic tree was constructed using the maximum‐likelihood approach in RAxML‐NG with default parameters and a constrained topology in Newick format .Nuclear ribosomal internal transcribed spacer (ITS) and chloroplast DNA  as an independent variable using the “cophenetic” function in the R package stats, and all independent variables were standardized by subtracting the mean and dividing by the standard deviation.The dormancy data were not normalized. Therefore, nonparametric analysis of variance (nonparametric ANOVA) with the Kruskal–Wallis test was used to assess dormancy percentage differences among species using the “kruskal.test” function in the hier.part package to assess the relative importance of each climatic variable  from step 1 using the “glmulti” function in the glmulti package, and (3) we calculated Spearman rank correlations of the residuals of the best model with phylogenetic distance and elevation using the “cor.test” function in the stats package. All statistical analyses were conducted using R v.4.0.2 , and no germinants found in I. arguta, I. lecomtei, or I. xanthina , Bio1  was negatively associated with SDS  were significantly correlated with phylogeny  in the Mediterranean show similar requirements for seed dormancy release. Here, seed dormancy of closely related Impatiens species showed a similar response to changing environments due to the phylogenetic constraints on plant seed dormancy.We detected significant variation in seed dormancy proportion and strong phylogenetic signals in s et al.  reporteds et al.  reported4.2Impatiens species. This suggests that genetics may be the most important factor influencing SDS variation in Impatiens species in the mountains of southwest China, corresponding to the significant phylogenetic signal of SDS. Evidence suggests that seed dormancy is an adaptive trait that depends on the cumulative action of many genes  grown in high‐temperature habitats require higher heat to release seed dormancy  with decreasing precipitation  and elevation, suggesting that climatic factors drive the elevational pattern of SDS variation in Impatiens species in the mountains of southwest China. This finding is consistent with previous research showing that soil temperature drives the allocation of reproductive biomass along elevation ; data curation ; investigation ; writing – original draft (lead). Zi‐Hong Chen: Data curation ; writing – review and editing . Yuan‐Yuan Huang: Data curation ; investigation . Zhong‐Hua Jiang: Data curation ; investigation .The authors declare no conflicts of interest.Appendix S1.Click here for additional data file.


Over the last two decades, much effort has been made to further extend the scope of biocatalytic reactions available to synthetic chemists, particularly by expanding the repertoire of enzymes for abiological transformations. In this regard, exciting new developments in the area of photobiocatalysis enable now the introduction of non‐natural reactivity in enzymes to solve long‐standing synthetic challenges. A recently described example from the Hyster group demonstrates in an unprecedented way how the combination of photochemistry with enzyme catalysis empowers the catalytic asymmetric construction of C sp3−Csp3 cross‐electrophile coupling, a reactivity previously unknown to enzymes.The combination of photochemistry with enzyme catalysis offers exciting opportunities to induce new reactivities and to create novel enzymes for reactions other than their native ones. Recently, Hyster and co‐workers demonstrated this for a photoenzymatic asymmetric C Enzyme catalysis intrinsically offers several advantages over traditional synthesis routes. Thus, biocatalysts are increasingly adopted by the pharmaceutical and chemical industries. However, many synthetically useful reactions cannot be performed with naturally occurring enzymes, limiting their expanded use in chemical synthesis. In the quest to expand the repertoire of enzymes for abiological transformations, different concepts have been devised and emerged into a hotbed of research.de novo design has been used to create an enzyme that catalyzes a Kemp elimination reaction . 0 1b). 5 sp3−CIn this reaction, the ERED fulfills two particular functions, making this approach so powerful. First, by using light to excite the enzyme‐templated CT complex formed between the alkyl halides and the flavin cofactor, the chemoselective reduction of the alkyl halide over the thermodynamically favored nitroalkane partner is enabled. Secondly, the ERED is precisely controlling the radical‐terminating HAT step and is thus forming the cross‐coupled product with high enantioselectivity.1 and 1‐nitroethylbenzene 2 afforded the desired cross‐coupled product. By choosing two stereocomplementary EREDs, both enantiomers of product 3 were accessible. Interestingly, performing the reaction with the photocatalyst Ir(ppy)3 instead of the ERED, the nitroalkane reduction to the oxime was observed, highlighting that this reactivity is unique to biocatalysis. After having optimized the reaction conditions, the authors sought to explore the scope and limitations of this photoenzymatic transformation. For instance, a variety of nitroalkanes were screened for their potential to serve as XEC partners with 1, while most of them were efficiently converted to the desired enantioenriched products with excellent enantioselectivity. As for the alkyl halide scope, secondary as well as tertiary amides provided the corresponding products in moderate to good yields and enantioselectivities.Astonishingly, many of the initially screened EREDs for the selected model reaction between α‐chloroamide sp3−Csp3 bond‐forming reactions empowered by photoexcited enzymes. While the scope was demonstrated for a wide range of coupling partners, it is expected that this concept will further leverage unprecedented chemo‐ and enantioselective sp3‐sp3 XEC. As this reactivity is unknown in small‐molecule catalysis, it demonstrates the power of accessing unnatural enzymatic reactions by exploring the interface between photochemistry and protein science. Moreover, this striking example further highlights that previous limitations in the reaction scope of enzymes are more and more overcome, thereby addressing long‐standing synthetic challenges.To conclude, Fu et al. have demonstrated a completely new strategy for performing enantioconvergent CThe authors declare no conflict of interest.


In 2009, Jencks and colleagues published their landmark New England Journal of Medicine paper on readmissions in the Medicare fee‐for‐service program. Their conclusion was simple: “Rehospitalizations among Medicare beneficiaries are prevalent and costly.”The seemly logical origin of the HRRP followed the teaching of Peter Drucker who stated, “If you can't measure it, you can't improve it”—a quote featured prominently on the Centers for Medicare & Medicaid Services (CMS) Measures Management website.1and re‐hospitalization are billed as an inpatient stay, but will be invisible under the HRRP if either hospitalization is billed as an outpatient observation stay. This is not just a theoretical problem: nearly one in five 30‐day rehospitalizations for HRRP target conditions are not counted under the HRRP due to observation stay as index, 30‐day rehospitalization, or both.The omission of observation hospitalizations from the HRRP “rehospitalization” metric is perhaps the most obvious shortcoming that has emerged.or inpatient stays within 30 days of the index inpatient stay.The blurry line between observation and inpatient care has raised concerns about whether hospitals might strategically encourage physicians to categorize their patients as outpatient (observation) instead of inpatient  within 30 days of an index inpatient stay to improve their readmission rate. As part of the 21st Century Cures Act of 2016, Congress mandated the Medicare Payment Advisory Commission (MedPAC) study this question, with MedPAC concluding there was not “…a shifting of short‐stay admissions into observation stays to avoid readmission penalties” in their 2010–2016 analysis.both the index hospitalization and 30‐day rehospitalization counts. Recently, Sabbatini and colleaguesAlthough key additions to the literature, many2In this issue of Health Services Research, Wright and colleaguesappropriate use of observation stays based on CMS rules and regulations. Here is why: the HRRP only counts inpatient stays, but the proportion of hospital stays now classified as outpatient observation has grown for reasons that likely include improved hospital efficiency resulting in acute‐care hospital stays shorter than two‐midnights designated as observation, and changes in visit status rules, such as hospital‐based procedures being removed from Medicare's “Inpatient‐Only List.” Thus, the problem of the HRRP is not misuse of observation but rather shifts in CMS policy that increases observation hospitalizations, further exposing the flaw in HRRP itself that fails to account for hospitalizations not billed as inpatient stays.Although counterintuitive, this study adds to the body of literature confirming the problem of observation stays in the HRRP actually relates to the This distortion of the HRRP's rehospitalization metric has worsened over time as outpatient hospital care continues to grow. According to the MedPAC, from 2006 to 2016, outpatient services increased by 49.0% while inpatient discharges decreased by 21.8%.3Could the HRRP be improved if observation stays were included? The most obvious and significant implication would be on the current Medicare hospital reimbursement model. Under CMS' Outpatient and Inpatient Prospective Payment Systems (OPPS and IPPS), observation stays can have dramatically different hospital payments than inpatient stays, even if the primary diagnosis and actual services proved are similar.Eliminating observation stays as a separate hospital visit status entirely—meaning all hospital stays would simply be considered hospital inpatient admissions—would be a significant improvement, but this degree of policy shift would have far‐reaching implications and is unlikely to happen. Additionally, solving the observation issue fixes only one of the many visit‐type or place of service issues under the HRRP. For example, ambulatory surgery center (ASC) use continues to grow, with one estimate projecting 25% growth between 2019 and 2029.Many other challenges remain. Although CMS “…encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions,”The growing proportion of Medicare Advantage (MA) enrollees also changes the readmission dynamic. When the HRRP began in 2012, 27% of Medicare beneficiaries were enrolled in an MA plan. In 2022, that number was 48%.Most importantly, the HRRP has failed to adequately account for social determinants of health. Living in a disadvantaged neighborhood predicts readmissions to a degree similar to having a chronic medical condition, like peripheral vascular disease.4The HRRP is begging for reform, yet what is the solution? In February 2023, the CMS signaled its intent to include all‐cause readmissions in its Universal Foundation of aligned quality measures.“If you can't measure it, you can't improve it”—applies to the performance of the HRRP itself. The HRRP has been measured for over a decade and the program is in dire need of a comprehensive overhaul. Legislators and regulators must engage in efforts to improve the HRRP on the policy level so it can truly deliver on its stated goal of improving hospital and healthcare quality.Dr. Powell receives support from the National Institute on Aging (R21AG079277) unrelated to this article. Dr. Sheehy receives support from the National Institute on Aging (3RO1AG070883‐02) unrelated to this article. This material is the result of work supported by the resources and the use of facilities at the University of Wisconsin School of Medicine and Public Health Center for Health Disparities Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.


Many plant viruses have been engineered into vectors for use in functional genomics studies, expression of heterologous proteins, and, most recently, gene editing applications. The use of viral vectors overcomes bottlenecks associated with mutagenesis and transgenesis approaches often implemented for analysis of gene function. There are several engineered viruses that are demonstrated or suggested to be useful in maize through proof‐of‐concept studies. However, foxtail mosaic virus (FoMV), which has a relatively broad host range, is emerging as a particularly useful virus for gene function studies in maize and other monocot crop or weed species. A few clones of FoMV have been independently engineered, and they have different features and capabilities for virus‐induced gene silencing (VIGS) and virus‐mediated overexpression (VOX) of proteins. In addition, FoMV can be used to deliver functional guide RNAs in maize and other plants expressing the Cas9 protein, demonstrating its potential utility in virus‐induced gene editing applications. There is a growing number of studies in which FoMV vectors are being applied for VIGS or VOX in maize and the vast majority of these are related to maize–microbe interactions. In this review, we highlight the biology and engineering of FoMV as well as its applications in maize–microbe interactions and more broadly in the context of the monocot functional genomics toolbox. A review of foxtail mosaic virus clones engineered for applications such as virus‐induced gene silencing, protein overexpression, gene editing, and virus‐induced flowering. However, many plant viruses have been engineered to exploit their unique characteristics for positive aims. These engineered viruses have been characterized and utilized in plants for gene silencing, gene expression, and gene editing applications. The use of virus‐based vectors for gene function analysis in the field of plant biology has been exceptionally valuable for experiments in both model and non‐model organisms, and recent comprehensive reviews are available that describe many vectors and their applications  is a key cereal crop that is grown worldwide and is an important model species. There are many genetic and genomic resources available to facilitate gene function analyses, and over the years a growing number of virus‐based vectors have been reported to be useful in maize. At the present time, there are at least 11 different virus species that have been tested in maize for their utility in VIGS, VOX, and/or VIGE (Table GE Table .phytoene desaturase (ZmPds) in maize seedlings , brome mosaic virus (BMV), and maize rayado fino virus (MRFV) . FoMV is becoming routinely used for VIGS and VOX, and it can deliver functional guide RNAs that can direct genome edits in maize plants expressing Cas9 protein, showing that it has potential for VIGE applications. For the remainder of this review we focus on FoMV biology and its engineering and use in gene function studies in maize and other monocots, and contributions of FoMV VIGS and VOX to investigating maize–microbe interactions are highlighted.2Setaria viridis (green foxtail) in a field in Kansas, United States , Sorghum bicolor (sorghum), Setaria spp. (millets), and Triticum aestivum (wheat)  , and because this virus is incapable of movement, protein expression occurs only at the site of infiltration. Local expression of the foreign protein is dramatically enhanced by co‐expression of the tomato bushy stunt virus (TBSV) p19 gene silencing suppressor. This approach works well for high levels of protein expression in plants such as Nicotiana benthamiana that support efficient agroinfiltration and replication of FoMV amplicons in the presence of p19.The first infectious clone of FoMV was generated by Robertson et al. , and it pds in sweetcorn (Golden x Bantam) and in the inbred B73 genotype was achieved. Expression of lesion mimic 22 (les22), iojap, and brown midrib 3 was also silenced in sweetcorn, but only down‐regulation of les22 and iojap resulted in the expected phenotype. The FoMV isolate was also tested for its ability to infect a panel of 10 maize inbred lines, and all of them except Mo17 were susceptible. These results suggest that FoMV can be used for VIGS in a broad range of maize germplasm. The inability of the FoMV clone to infect Mo17 maize is consistent with prior work showing that Mo17 has resistance to FoMV through a quantitative trait controlled by eight loci . A 200‐nucleotide (nt) sequence targeting barley pds was cloned into this virus, but it induced only mild VIGS. However, when short, inverted repeat sequences were cloned at this position, robust silencing of target genes was observed in barley , foxtail millet , Isopentenyl/dimethylallyl diphosphate synthase), and wheat . The use of this vector for VIGS in maize was not reported.Liu et al.  developeN. benthamiana to generate an inoculum that can be used to infect wheat, maize, or other monocots. PV101 was used to express the 600 amino acid GUSPlus protein in wheat and maize, demonstrating its ability to spread systemically as it carries an 1800‐nt insert. Furthermore, the authors demonstrated that expression of pathogen effector proteins was feasible via the delivery of the fungal pathogen Stagonospora nodorum ToxA protein, which induced cell death as expected in wheat.Bouton et al.  developeGFP) and bialaphos resistance (BAR) in maize plants where the expected phenotypes of green fluorescence and resistance to glufosinate herbicide, respectively, were observed.Mei et al.  modified4For viral vectors to become broadly utilized for functional genomics and gene editing delivery systems, it is necessary to have efficient and accessible plant inoculation methods. Current methods for launching viral infections from infectious clones include in vitro transcription followed by vascular puncture inoculation (VPI), rub‐inoculation, or particle bombardment to introduce infectious RNA transcripts into plants. Alternatively, DNA constructs encoding the viral genomes under plant promoters can be introduced using VPI, rub‐inoculation, particle bombardment, and agroinfiltration. Each method has advantages and limitations associated with it. If the viruses are mechanically transmissible, the inoculated leaves and/or systemically infected leaves of a few inoculated plants can be stored for later use to inoculate many experimental plants using rub‐inoculations or VPI  but not others . To bypass the need to first use N. benthamiana for generating FoMV inoculum, Beernink et al.  is susceptible to FoMV or not e.g., Mo17). If there are options, then selection of the particular FoMV vector could be a consideration. At this time, we are not aware that the different vectors  was stably maintained at 21 days postinoculation (dpi) in 72%–90% of plants, but a 300‐nt insert targeting ubiquitin (SbUb) was stably maintained in only 36%–45% of the plants in sorghum genotype BTx623  correlated with the loss of insert  were cloned in the antisense orientation into the Mei et al.  loci affecting Rp1‐D21 function identified through genome‐wide association studies (GWAS). For three of the genes , there was no successful silencing. The remaining nine genes, plus Rp1‐D21, were silenced between approximately 1.6‐ and 17‐fold. Of these, four genes suppressed HR when silenced , demonstrating that they are required for Rp1‐D21 function, three genes enhanced the Rp1‐D21‐HR when silenced , and for another three genes, silencing them had no effect on the phenotype . These data show that VIGS can be used to validate gene function predictions based on functions of homologous genes in other species and from GWAS.In the largest‐scale VIGS study in maize to date, Murphree et al.  used the6.3Maize chlorotic mottle virus (MCMV) causes maize lethal necrosis when it co‐infects maize along with unrelated viruses, such as potyviruses like SCMV  through protein pull‐down and tandem mass spectrometry. Silencing ZmTGL1 reduced its mRNA transcripts by 50% and resulted in a 2–3‐fold greater accumulation of SCMV. This silencing phenotype is consistent with a role for ZmTGL1 in reducing the accumulation of SCMV HC‐Pro, which is a silencing suppressor required for efficient replication of SCMV.Xu et al.  used theol Table . ZmTGL w7Engineering viruses to deliver gene editing components has been a rapidly expanding area of research. The use of viral vectors overcomes bottlenecks associated with traditional transgenesis methods that are needed to introduce gene editing reagents into plants , and transcription activator‐like effector nucleases (TALENs) are all genome editing platforms with a high level of target specificity, but they are limited by challenges in modifying that specificity , and they occurred in leaves and flowers over the course of plant development , which is a potyvirus that promotes greater accumulation of FoMV and other viruses through the action of its silencing suppressor. Unfortunately, the boost in FoMV accumulation in the presence of TuMV is lethal to the plant , one biomass crop species (Panicum virgatum), and two weed species (S. viridis and Alopecurus myosuroides). Success in these organisms coupled with the broad experimental host range of FoMV suggests that there are many additional species that currently lack gene function analysis or plant transformation technologies for which FoMV‐based vectors can be utilized.It is exciting to see that FoMV‐based resources and their corresponding protocols are being adopted successfully by many laboratories. While FoMV has been applied mainly for research in maize–microbe interactions at this time, we anticipate that it will be useful in studying the functions of genes involved in other aspects of maize biology. A major rationale for engineering FoMV for VIGS and VOX applications was its reportedly broad host range, particularly in monocots (Scofield & Nelson, The authors declare no conflict of interest.


We report a 35‐year‐old woman who presented with dyspnoea and chest pain for 1 week. High‐resolution computed tomography (HRCT) thorax revealed bilateral pneumothoraces with diffuse lung cysts. Bilateral intercostal chest tubes were inserted, and there was a persistent air leak (PAL) bilaterally. We performed an autologous blood patch pleurodesis (ABPP) for the left PAL. For the right PAL, she underwent a successful right video‐assisted thoracic (VATS) surgery, wedge biopsy, and surgical pleurodesis. Histopathology examination confirmed the diagnosis of lymphangioleiomyomatosis (LAM). The left pneumothorax recurred. An indwelling pleural catheter  was inserted and the patient was discharged after 1 day with an atrium pneumostat  chest drain valve. The patient was initiated on Sirolimus 2 mg daily. The left PAL resolved at 6 weeks. This case highlights the benefit of IPC with an ambulatory pneumothorax device in a patient with LAM with PAL. Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease with the progressive formation of numerous small cysts. The course of the disease is complicated by recurrent pneumothoraces. This occurs due to cyst rupture into the pleural space or through alveolar wall disruption resulting in an air leak. Chemical or surgical pleurodesis is performed to prevent a recurrence. Persistent air leak (PAL) can complicate this condition. We report the successful use of IPC with an ambulatory pneumothorax device in a patient with LAM with PAL. Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease with the progressive formation of numerous small cysts. The course of the disease is complicated by recurrent pneumothoraces. This occurs due to cyst rupture into the pleural space or through alveolar wall disruption resulting in an air leak. Chemical or surgical pleurodesis is performed to prevent a recurrence. PAL can complicate this condition. We report the successful use of IPC with an ambulatory pneumothorax device in a patient with LAM with PAL.A 38‐year‐old woman was referred to the respiratory clinic with progressive exertional dyspnoea for 6 months. There was no cough, fever, or weight loss. The respiratory examination was unremarkable. Chest radiograph showed bilateral cystic changes. A working diagnosis of LAM was made. High‐resolution computed tomography (HRCT) thorax revealed diffuse thin‐walled cysts bilaterally. Detailed clinical evaluation including dermatologic and retinal examination did not reveal any evidence suggestive of tuberous sclerosis. Abdominal ultrasonography showed no evidence of associated angiomyolipoma, lymphangioleiomyoma, or lymphadenopathy. The patient declined video‐assisted thoracoscopic surgery (VATS) lung biopsy to confirm the diagnosis.She presented 6 months later with bilateral pneumothoraces. The oxygen saturation was 94% on room air, respiratory rate of 24 breaths per minute, blood pressure of 110/62 mmHg and heart rate of 96 beats per minute. Respiratory examination revealed bilateral reduced breath sounds. Bilateral chest tubes size of 24 Fr were inserted Figure . HRCT thThere was continuous bubbling in both underwater seal devices on day 5 with radiographic evidence of partially expanded lungs bilaterally. The patient was unfit for single‐lung ventilation for the VATS repair of the PAL. We performed an ABPP for the left PAL with the instillation of 2 mL/kg of autologous blood. The left PAL persisted at 72 h requiring a further two ABPP. The left PAL was resolved after 1 week.After 1 week, the patient underwent a successful right VATS with apical wedge resection, surgical stapling of the right apical lobe, and mechanical pleurodesis to achieve interpleural symphysis. The left PAL recurred 1 day after the VATS for the right PAL. The patient refused further surgical intervention. A decision was made to insert an IPC with an ambulatory pneumothorax device Figure . She wasLymphangioleiomyomatosis (LAM) is a rare cystic lung disease, which can occur sporadically or in association with tuberous sclerosis. LAM predominantly affects females of child‐bearing age. It is characterized by the proliferation of smooth muscle‐like cells throughout the interstitium of the lung and spread via the lymphatic tracts.The commonest chest radiograph abnormality is reticulonodular shadowing and cysts or bullae with preserved lung volumes.The definitive diagnosis of LAM requires characteristic CT findings and a lung biopsy showing the characteristic histological features of LAM and reactivity with HMB‐45. A biopsy is not needed when there is presence of tuberous sclerosis complex, angiomyolipoma, chylous effusions, lymphangioleiomyoma, or high VEGF‐D value (greater than 800 pg/mL) in a patient with typical CT findings.The initial approach to pneumothorax in LAM is similar to other lung diseases. Surgical intervention is considered in recurrent pneumothoraces or PAL. The persistence of pneumothorax with PAL beyond 3–5 days requires evaluation for surgery to close the air leak followed by pleurodesis.Autologous blood patch pleurodesis (ABPP) and endoscopically placed ‘one‐way’ endobronchial valves have demonstrated succes in patients unfit or refuse surgery.ABPP is comparable in efficacy to talc, tetracycline, or silver nitrate in achieving pleurodesis with less pain, fever and shorter length of hospitalization.The subsequent application of an IPC with the transition to an ambulatory drainage device allowed the leak to heal and reduced the length of hospitalization. The literature review pertaining to the treatment of LAM and pneumothorax is shown below Table . The majTreatment with Sirolimus stabilizes pulmonary function, prevents pneumothorax recurrence, improves oxygenation, exercise capability, and quality of life in LAM.PAL in secondary pneumothorax is a clinical challenge as many patients are unfit for surgical intervention. Blood patch pleurodesis or IPC with an ambulatory pneumothorax device is a useful and safe alternative option for these patients.Andrea Ban Yu‐Lin is an Editorial Board member of Respirology Case Reports and a co‐author of this article. They were excluded from all editorial decision‐making related to the acceptance of this article for publication. Andrea Ban Yu‐Lin is an Associate Editor for the Journal. The other authors have no conflict of interest to declare.The authors declare that appropriate written informed consent was obtained for publication of this case report and accompanying images.


Conventional testing methods for dermatophytes are time‐consuming, and resource limitations in our institution have prompted curtailed access to these diagnostics.Evaluation of our hospital's dermatological mycology diagnostic services and similar services nationally.This was a retrospective observational study on skin, hair and nail mycology samples in our institution comparing twenty five‐year periods (2011–2015 and 2016–2021), including analysis of dermatology clinic data and correspondence related to fungal infection. A survey of national public hospitals' laboratories was conducted to evaluate their mycology testing capabilities.n = 4344) from general practice and 6% (n = 290) from dermatology clinics. For the 5 years post curtailment, 64.5% (582/903) of specimens were from dermatology clinics. Dermatology clinic data demonstrated doubling of attendances  and of correspondence related to fungal infection. During this time also, national dermatological antifungal purchasing increased 11%. Ten of 28 Irish public hospital laboratories reported the provision of in‐house dermatological mycology testing, and none had routine availability of susceptibility or molecular testing of dermatophytes.The total 5 year test count prior to curtailment was 4851 specimens comprising 90% (This study is the first to report an appraisal of dermatological fungal diagnostic services in Ireland. Insufficient testing capacity implies that patients are either being treated for fungal infection without appropriate diagnostic confirmation, or being left untreated because of the lack of access to diagnostics. The introduction of molecular detection methods and susceptibility systems would enhance testing capabilities and reduce the requirement for the external referral. This service is provided to public and private healthcare facilities in the region including general practice, for a population of circa 400,000 people. Of note, there are no electronic patient records in this group of hospitals. Previous related research from our institution includes fungal bloodstream infections in our ICU patients,2.3All mycology laboratory test counts from January 2001 to December 2021 were extracted from the Laboratory Information Management System , to provide an historical context to recent trends in the numbers of tests performed. For the period 2011–2021, a data extract of dermatology clinic attendance figures for the hospital was performed from the patient management system . Figures for the five‐year periods prior to and following July 2016 (when the change to testing methodology was implemented) were recorded. Similarly, a keyword search term count was performed of the patient clinical letters database  held at the dermatology clinic. The keywords ‘fungal’, ‘tinea’ and ‘onychomycosis’ were searched for in the letters of correspondence sent to general practitioners. The count of letters containing these keywords allowed a crude comparison to be made of the number of patients with these conditions seen in the periods before and after access to diagnostics was restricted.A survey was performed in all of the 28 public hospital Microbiology laboratories of Ireland to determine how many of those laboratories performed in‐house mycology testing of skin, nail and hair samples, and which of them routinely performed polymerase chain reaction (PCR) and/or susceptibility testing of dermatophytes and non‐dermatophyte moulds. The respondents were invited to supply test count data if they wished. This survey took the form of an e‐mail request in January 2022 and subsequent follow‐up of non‐responders.The pharmaceutical suppliers of the main dermatological anti‐fungal agents were contacted by e‐mail in January 2022, with follow‐up e‐mails for non‐responders. The companies were asked for details of the number of their unit sales per product for the Irish state and/or for the Mid‐West region of Ireland, especially data from 2011 to 2021 where possible. The companies were Brown and Burk IR Limited, GlaxoSmithKline Consumer Healthcare (Ireland) Limited, Novartis Ireland Limited, Viatris Global Healthcare T/A Mylan Limited, Johnson & Johnson Limited and Janssen Sciences Ireland.Data were analysed using Microsoft Excel.3For the five‐year period 2011–2015, the median number of skin, hair and nail specimens for mycology analysis received in our laboratory from general practitioners (GPs) was 855 specimens per annum. For the corresponding period following the restriction of access to this service (2017–2021), the median test count was 35 specimens per annum . The positivity rate (microscopy and/or culture) of these samples increased from 36.5% to 40% across these two periods. The dermatology clinic of our hospital showed an increase from 54 specimens per annum to 117 specimens per annum (117% increase) for the same two time periods and a reduction in the positivity rate from 30% to 27%. See Figure Total dermatology clinic attendance figures showed a similar increase over the two time periods. The median annual attendance for the clinic in the pre‐curtailment period was 2320 and the corresponding figure post‐curtailment was 4570 attendances (97% increase). This increase was weighted more heavily in favour of paediatric patients (140% increase) rather than adult patients (94% increase). See Figure The results for the count of letters from the patient letters database of the dermatology clinic with matches for the specific search terms ‘fungal’, ‘tinea’ and ‘onychomycosis’ also showed an increase. The total number of letters per annum in the pre‐curtailment period was 65 letters , and there were 127 letters per annum  in the post‐curtailment period – a 95% increase. See Figure In January to March 2022, a survey of the Microbiology laboratories of the public health service system  hospitals in the Republic of Ireland revealed that 10 of the twenty‐eight laboratories continue to perform in‐house fungal testing of skin, hair and nail samples. See Figure The laboratories were also asked whether they had curtailed access to their fungal testing of skin, hair and nails, and were invited to supply test count data. Two hospitals supplied 10 years of test count figures, one from the south of the country  and one from the east of the country , neither of which has had to restrict access to mycology diagnostic services, see Figure Brown and Burk IR Limited : No response.GlaxoSmithKline Consumer Healthcare (Ireland) Limited : No data available.Novartis Ireland Limited : Data for 2017–2021 supplied.Viatris Global Healthcare T/A Mylan Limited : Data for 2018–2021 supplied.Johnson & Johnson (Ireland) Limited : Data for 2017–2021 supplied.Janssen Sciences Ireland : Data for 2017–2021 supplied.In February 2022, the following pharmaceutical companies were contacted for sales data (11 years of data if possible) on their dermatological anti‐fungal products, and their responses are included below:No data prior to 2017 were available, but the data provided for the period 2017–2021 (excluding Nailderm tablets) showed a 12.5% increase in product sales. The data for 2018–2021 (including Nailderm tablets) showed an 11% increase in product sales. Figure 4Local pharmacy sales data were not available for the study. The Primary Care Reimbursement Service (PCRS) was contacted for antifungal reimbursement claims data. No data were available by the time the study concluded.5n = 95), tinea versicolor/corporis  tinea pedis  and tinea faciei . Where a geographical region is mentioned in the title (n = 423), regions in Asia were the most common , followed by Africa , Europe , the Middle East , North and South America  and Oceania . No recent reports of outbreaks are available from Ireland, although a study from Dublin in 2006 described a disproportionate (85.5%) number of patients of African extraction among their paediatric tinea capitis patients.The incidence of fungal skin infections is increasing at an alarming rate worldwide.The results of this study demonstrated a dramatic reduction in the processing of specimens for fungal analysis from GPs after curtailment of mycology diagnostic services. The corresponding increase in dermatology clinic samples did not fill the gap left by this drop in community specimens, which could be explained in part by patients being treated for fungal infection without appropriate diagnostic confirmation, or being left untreated because of the lack of access to diagnostics. Clinical papersT. indotineae are highly prevalent,Antifungal resistance has been called a ‘global public health threat’.MALDI‐TOF MS (matrix‐assisted laser desorption/ionisation time‐of‐flight mass spectrometry) instrumentation has been reported to be capable of identifying dermatophytes,tm Dermatophyte Assay’ (Seegene).Nucleic acid amplification tests have replaced many of the conventional diagnostic techniques of the microbiology laboratory, and mycology testing is no exception. The poor sensitivity of microscopy and culture, particularly after the onset of empirical treatmentOther studies have shown that the widespread use of over‐the‐counter antifungals may be promoting resistance, most notably to the azole drugs, which can mean that oropharyngeal, vaginal or even systemic yeast infections may need to be treated with less desirable alternatives such as amphotericin B with possible complications and renal toxicity.Dermatological mycology testing has not been prioritised in many laboratories around the world, including our own, yet there is growing international evidence of increased incidence of infections and resistance to anti‐fungal agents. In Ireland, we have a growing population and increasing immigration, yet the testing capacity of our laboratories are being curtailed, susceptibility testing of dermatophytes is not being performed and new technologies have not been adopted. Furthermore, there is suboptimal epidemiological tracking of organisms and their antifungal susceptibilities, and there is no national oversight. Dermatological fungal infections are commonly misconceived as a cosmetic problem, but left untreated they can cause pain, physical impairment, increased risk of infections such as cellulitis and osteomyelitis in immunocompromised or diabetic patients, and a significant negative impact on quality of life.JP: Conceptualisation ; Writing–original draft (lead); Data curation (lead); Methodology (lead); Writing–review and editing . EP: Conceptualisation ; Writing–original draft (supporting); Writing–review and editing ; SR: Writing–original draft (supporting); Writing–review and editing . SF: Conceptualisation ; Writing–original draft (supporting); Writing–review and editing . NOC: Conceptualisation ; Writing–original draft (supporting); Writing–review and editing . CPD: Conceptualisation ; Writing–original draft (supporting); Writing–review and editing .This study was performed as part of a PhD program for the lead author (JP). Funding for the PhD was provided by University Hospital Limerick and the Corresponding Author at the University of Limerick.The authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest, or non‐financial interest in the subject matter or materials discussed in this manuscript that would constitute a conflict of interest.All the authors have revised the manuscript critically and have approved the final draft.Appendix S1Click here for additional data file.


The physiological impact of declining oestrogen levels during menopause has been well documented. We conducted a literature review to assess the impact of menopause on oral health. Falling oestrogen levels are associated with adverse effects on the gingival, oral and buccal epithelia. The symptoms prevalent in perimenopausal and postmenopausal women range from dry mouth to immune‐mediated mucocutaneous disease and burning mouth syndrome. Our review has highlighted the need for further research into potential treatments for oral symptoms in menopause, particularly with regard to hormone replacement therapy. Menopause is defined as a point 12 months after a woman's final period, and starts on average between the ages of 45 and 55 years.The Cochrane Library, National Institute for Health and Care Excellence (NICE) Evidence database and the Turning Research into Practice database were searched from 2001 to 2021. In total, 116 original research articles were found on menopause in dermatology, 13 of which related to oral health in menopause. Individual searches were performed for specific queries related to our paper.Oestrogen is well known for its role in cell growth and regulation, and acts through oestrogen receptors (ERs), which are found throughout the body. There are two different subtypes of ERs: ER‐α is found in oestrogen target tissues and in the mouth, while ER‐β is the predominant receptor found in the gingiva, buccal epithelia and salivary glands.et al.Oestrogen plays a role in angiogenesis, vascular permeability and fibroblast mediation. Fluctuations in oestrogen levels and bone mineral density have been found to exaggerate the loss of alveolar bone, causing deterioration of periodontal health and ultimately leading to tooth loss.et al.A systematic review by Allen Microscopic examination of the buccal and vaginal epithelia has demonstrated structural similarities.Saliva is necessary for maintaining oral health, facilitating digestion and providing an antimicrobial defence mechanism.et al.et al.Xerostomia is the subjective feeling of dry mouth while hyposalivation is the objective reduction in salivary flow.Immune‐mediated mucocutaneous diseases with oral involvement are generally more prevalent in women in the fourth and fifth decades of life.Oral lichen planus (OLP) is an inflammatory autoimmune disease of the mucous membranes. The current literature shows that OLP is more prevalent in women and in people aged > 40 years.et al.Management of OLP includes a variety of topical, systemic and nonpharmacological preparations, listed in Table Burning mouth syndrome (BMS) is a multifactorial illness affecting approximately 10–40% of perimenopausal women. It is characterized by a burning sensation in the anterior aspect of the tongue, hard palate or lower lip mucosa.The physiological impact of the menopause on oral health often causes chronic discomfort and a reduced quality of life (QoL). Symptoms include dry mouth, increased oral infections and deterioration of periodontal health. What has been highlighted from our review is the need for large, longer‐term randomized controlled trials (RCTs) to fully assess the management of oral symptoms and the potential role of HRT. Dermatologists should be aware of the potential implications of menopause on oral health, and encourage patients to maintain routine appointments with dentists and practise good oral hygiene.This series on menopause has highlighted the multifaceted effect of menopause on common dermatoses and the associated adversarial effect on the QoL of menopausal women. Understanding the mechanism of fluctuating hormone levels and its cutaneous manifestation, could lead to better targeted therapy in the future. We have demonstrated a need for large, long‐term RCTs on the potential role of HRT as a therapeutic option for hair, skin, vulval and oral health.There is a significant psychosocial impact oral discomfort can have on women during the premenopausal and postmenopausal period.Given the similarities between the vaginal and oral mucosa, more research is needed on the effect of the oral microbiome during menopause.Reduced salivary flow, xerostomia and BMS are all associated with the postmenopausal state and can have a significant impact on QoL.Immune‐mediated mucocutaneous diseases are more prevalent in women in their fourth and fifth decades.Dermatologists should ensure menopausal patients are seeking regular dental care and practising good oral hygiene.The use of HRT for oral discomfort seen in menopause requires further research in the form of large RCTs.The authors declare that they have no conflicts of interest.Funding for open access was provided by the University of Sussex as CDG is an honorary senior clinical lecturer for the university.Ethics approval and informed consent not applicable as this was a literature review.Not applicable.To gain knowledge on menopause, hormonal status and associated oral disorders.(a) Oestrogen receptor (ER)‐α is the receptor predominantly seen in the mouth.(b) ER‐β is the receptor predominantly seen in the mouth.(c) Oestrogen causes degradation of collagen tissue in the mouth.(d) Reduction in progesterone levels results in inhibition of gingival fibroblasts.(e) Sex hormones do not have a direct action on oral tissues.Which of the following statements about the effect of sex steroids in the mouth is correct?(a) Salivary glands do not contain oestrogen receptors and are therefore protected from the fluctuation of hormone levels.(b) Reduced salivary flow can lead to the development of periodontitis.(c) Alterations in salivary composition during the menopause include increased levels of sodium in saliva.(d) Hormone replacement therapy (HRT) has been well established as a treatment for the uncomfortable symptoms of dry mouth.(e) Salivary flow rates are the same in menstruating and menopausal women.Which of the following statements about salivary flow in menopause is correct?(a) OLP is more common in women than men.(b) OLP affects perimenopausal and premenopausal women equally.(c) Oestrogen plays a minimal role in T‐cell regulation in immune‐mediated mucocutaneous disease.(d) Systemic treatment is generally preferred as a first‐line treatment for OLP.(e) Biologic agents have not been studied as a treatment option for OLP.Which of the following statements about oral lichen planus (OLP) is correct?(a) Topical tacrolimus 0.1% cream.(b) Topical triamcinolone acetonide 0.1% gel.(c) Oral azathioprine 150 mg/day.(d) Oral gabapentin 300 mg/day.(e) Photodynamic therapy.According to the literature, which of the following agents has not been reported as a treatment option in oral lichen planus?(a) Complete resolution of symptoms occurs in 90% of individuals.(b) Severe cases of BMS do not benefit from anticonvulsants such as gabapentin.(c) Clonazepam 10 mg tablet held in mouth for 7 min has been shown to reduce symptoms of BMS.(d) The use of hormone replacement therapy (HRT) in BMS has shown significant reduction in long‐term symptoms.(e) BMS can occur secondary to drugs, trauma and oral infections.Which of the following statements about burning mouth syndrome (BMS) is true?http://www.wileyhealthlearning.com/cedThis learning activity is freely available online at Read the article in print or online, paying particular attention to the learning points and any author conflict of interest disclosures.Reflect on the article.http://www.wileyhealthlearning.com/ced and answer the CPD questions.Register or login online at Complete the required evaluation component of the activity.Users are encouraged toOnce the test is passed, you will receive a certificate and the learning activity can be added to your RCP CPD diary as a self‐certified entry.This activity will be available for CPD credit for 2 years following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional period.


Enhanced signaling through RAS and the mitogen‐associated protein kinase (MAPK) cascade underlies the RASopathies, a family of clinically related disorders affecting development and growth. In RASopathies, increased RAS‐MAPK signaling can result from the upregulated activity of various RAS GTPases, enhanced function of proteins positively controlling RAS function or favoring the efficient transmission of RAS signaling to downstream transducers, functional upregulation of RAS effectors belonging to the MAPK cascade, or inefficient signaling switch‐off operated by feedback mechanisms acting at different levels. The massive effort in RASopathy gene discovery performed in the last 20 years has identified more than 20 genes implicated in these disorders. It has also facilitated the characterization of several molecular activating mechanisms that had remained unappreciated due to their minor impact in oncogenesis. Here, we provide an overview on the discoveries collected during the last 5 years that have delivered unexpected insights  and allowed to profile new RASopathies, novel disease genes and new molecular circuits contributing to the control of RAS‐MAPK signaling. In this review, we briefly outline the molecular mechanisms affecting RAS‐MAPK signaling in RASopathies and provide an overview on the novel disease genes and new RASopathies emerged in the last few years.During the last 10 years, the use of hypothesis‐free disease gene discovery approaches based on genome‐wide sequencing has facilitated the identification of additional RASopathy genes /guanosine diphosphate (GDP)‐binding GTPases functioning as molecular switches that control diverse cellular processes  by modulating a multifaceted signaling network , functionally converge to favor the dephosphorylated status of RAF1 at Ser259, which is a crucial step in RAF1 catalytic activation  provides evidence of multiple circuits implicated in the negative control of RAS function as a recurrent theme of RAS‐MAPK signaling upregulation in RASopathies , also known as extracellular signal‐regulated protein kinase 2 (ERK2), encoding the terminal tier of the MAPK cascade, joined the group of the signal transducers mutated in the RASopathies.Two years ago, nearly 20 years from the discovery of 185 and Tyr187, which are located within an “activation” segment, favoring a conformation of the catalytic domain stabilizing the active site  and is a required step for the inactivation of the kinase. The reversible phosphorylated state of these two residues controls the magnitude and duration of activation as well as the nuclear localization of the kinase, which, in turn, determines the nature of the cellular response to stimuli. Specificity in substrate binding is mainly attained by interactions mediated by two “docking sites,” named D‐recruitment site (DRS) and F‐recruitment site  and reduced growth are suggestive of NS. Congenital heart defects  were reported in a relatively high proportion of patients, although hypertrophic cardiomyopathy (HCM) has not been reported. Minor skeletal defects were also a common finding. None of the subjects has been diagnosed with cancer.De novo MAPK1 variants have a non‐random distribution and promote an increased phosphorylation of the kinase, which in turn enhances the translocation of the protein to the nucleus and boosts MAPK signaling  or perturbing the regulatory mechanism controlling the activation of the kinase (changes at residues Ile74 and Ala174). Functional studies showed that the defective negative regulation exerted by MKP3 , a dual‐specificity protein phosphatase negatively controlling ERK function, represents a generalizable mechanism for the gain‐of‐function (GoF) behavior of these pathogenic variants. Of note, previous work demonstrated that amino acid substitutions in or close to the DRS can lead to either GoF or loss of function (LoF) by impairing proper MAPK1 binding to regulators and substrates, respectively  is a common finding in cancer, MAPK1 mutations define a new RASopathy. Although two individuals of the original cohort had features suggestive of NS, systematic screening of the entire MAPK1 coding sequence in large cohorts of subjects with clinical diagnosis of RASopathy did not identify other pathogenic variants. This negative result suggests that MAPK1 mutations are a rare event in subjects with NS‐related features and could be more commonly identified in patients with unclassified syndromic DD/ID.Overall, de novo 3.2LZTR1 (MIM: 600574) was identified as a gene predisposing to schwannomatosis  is a widely expressed protein that localizes to the cytoplasmic surface of the Golgi network and is characterized by six tandemly arranged Kelch motifs at the N‐terminus and two BTB/POZ  domains at the C‐terminus  are negative regulators of signaling elicited by cell‐surface receptor tyrosine kinases. Specifically, they negatively control MAPK signaling by favoring neurofibromin binding to activated GTP‐bound RAS  have recently been identified as underlying a disorder clinically resembling NS . Shared features of the originally reported patients include DD/ID, facial dysmorphism , low posterior hairline with a webbed/short neck, and cardiac involvement (HCM and/or PVS). Short stature with relative macrocephaly was documented in three individuals, and typical NS chest anomalies and other skeletal defects (spine) were also common findings. No lymphedema or skin/ectodermal anomalies were noted except for the occurrence of deep palmar creases . A number of oncogenic variants have been reported in a variety of solid tumors, including carcinomas of the endometrium, prostate, lung and liver. These somatic mutations are missense and affect residues homologous to the cancer‐associated ones mutated in HRAS, KRAS and NRAS. Of note, the p.Gln72Leu change  was identified as driver event in isolated JMML , being originally cloned from a human teratocarcinoma cDNA library , identified prenatally due to macrosomia, hydrocephalus, Dandy Walker malformation, and suspected arrhythmia, was more recently reported , this subject showed a severe and rapid lethal course of NS. He also was diagnosed with JMML. These findings, which provide the first evidence of the occurrence of genotype–phenotype correlations for this gene, indicate that mutations in RRAS2 are generally associated with a classic NS phenotype , which encodes a member of the RRAS subfamily (see above). This GTPase is implicated in a wide array of cellular processes  by modulating multiple signaling pathways, including the MAPK and PI3K‐AKT cascades , a narrow spectrum of de novo variants has recently been reported in six patients with clinical diagnosis of NS  are well known hotspots for cancer‐associated and/or RASopathy‐causing mutations in other RAS proteins , similar to what has been reported for mutations in RIT1, PTPN11 and RAF1 (limited to specific classes), and LZTR1 . Two large cohorts of patients were systematically assessed for MRAS mutations  and are not reminiscent of Mazzanti syndrome suggests that the impact of dysregulated MRAS function on intracellular signaling is not equivalent to the dysregulation driven by upregulated SHOC2 and PPP1CB function. Another aspect requiring further investigation is the specific link between MRAS hyperactivation and HCM. Accumulated evidence indicates that both the MAPK and PI3K‐AKT–mTOR pathways contribute to HCM in RASopathies . This indicates that other genes are implicated in this family of disorders or that genocopies  account for these patients. We anticipate that the routine application of genomic sequencing in the clinical practice will enable answering this open question in the next few years and is expected to provide further insights on other molecular mechanisms and circuits functionally linked to RAS signaling.None.