Barrett’s esophagus (BE) is an abnormality arising from gastroesophageal reflux disease that can progressively evolve into a sequence of dysplasia and adenocarcinoma. Progression of Barrett’s esophagus into dysplasia is monitored with endoscopic surveillance. The current surveillance standard requests random biopsies plus targeted biopsies of suspicious lesions under white-light endoscopy, known as the Seattle protocol. Recently, published evidence has shown that narrow-band imaging (NBI) can guide targeted biopsies to identify dysplasia and reduce the need for random biopsies. We aimed to assess the health economic implications of adopting NBI-guided targeted biopsy vs. the Seattle protocol from a National Health Service England perspective. A decision tree model was developed to undertake a cost-consequence analysis. The model estimated total costs  and clinical implications of monitoring a cohort of patients with known/suspected BE, on an annual basis. In the simulation, BE patients  entered the model every year and underwent esophageal endoscopy. After 7 years, the adoption of NBI with targeted biopsies resulted in cost reduction of £458.0 mln vs. HD-WLE with random biopsies . The incremental investment on capital equipment to upgrade hospitals with NBI (+£68.3 mln) was offset by savings due to the reduction of histological examinations (-£505.2 mln). Reduction of biopsies also determined savings for avoided adverse events (-£21.1 mln). In the base-case analysis, the two techniques had the same accuracy (number of correctly identified cases: 1.934 mln), but NBI was safer than HD-WLE. Budget impact analysis and cost-effectiveness analyses confirmed the findings of the cost-consequence analysis. In conclusion, NBI-guided targeted biopsies was a cost-saving strategy for NHS England, compared to current practice for detection of dysplasia in patients with BE, whilst maintaining at least comparable health outcomes for patients. Barrett’s esophagus (BE) is a condition in which the typical squamous epithelium of the esophageal mucosa is replaced with columnar intestinal epithelium ,2. The pBE can progressively evolve into a sequence of low-grade dysplasia (LG-BE), high-grade dysplasia (HG-BE), and eventually esophageal adenocarcinoma (EAC) , a maligIncidence of EAC is expected to continue to increase . The preIn light of the increasing incidence and mortality burden associated with EAC, early detection of BE and surveillance of its progression into dysplasia and carcinoma are crucial clinical objectives in diagnostic endoscopy. Current guidelines recommend an endoscopic surveillance approach based on random four-quadrant biopsy specimens obtained at every 2 cm to detect dysplasia, in addition to targeted biopsies of suspicious lesions under white-light endoscopy (WLE), known as the Seattle protocol ,13. HoweIn the last decade, several imaging techniques have been developed with the aim of overcoming the typical diagnostic challenges in BE surveillance and improving the detection of dysplasia and EAC .The most well-studied, approved techniques include chromoendoscopy using acetic acid, confocal laser endomicroscopy (CLE), opto-digital chromoendoscopy with use of narrow-band imaging  with or without autofluorescence imaging . Such teMore specifically, a recent study comparing NBI vs high-definition white light endoscopy (HD-WLE) has shown that NBI: i) has the same intestinal metaplasia (IM) detection rate as an HD-WLE examination with the Seattle protocol while requiring fewer biopsies; ii) can detect more areas with dysplasia than HD-WLE .While the clinical implications of advanced imaging supporting BE detection has been extensively investigated , little is known regarding cost-effectiveness of these techniques. The aim of the present analysis is to assess the potential economic implications of adopting NBI-guided targeted biopsy for BE surveillance replacing the Seattle protocol, considered the current standard of care for screening and surveillance in BE, from a National Health Service (NHS) England perspective.A combined decision tree / Markov model approach was adopted to undertake cost-consequence, budget impact, and cost-effectiveness analyses of NBI with target biopsies  vs HD-WLE with Seattle Protocol  in the clinical management of BE from an NHS England perspective.The decision tree approach was used to model the diagnostic and surveillance phases. At the beginning of simulation, a cohort of patients with suspected BE enter the model to undergo an endoscopic test (with either NBI or HD-WLE) and receive one of the following diagnoses: i) non-dysplastic BE (ND-BE); ii) BE with low-grade dysplasia (LG-BE); iii) BE with high-grade dysplasia (HG-BE) or EAC. HG-BE and EAC were grouped together for the sake of simplicity as the recommended surveillance intervals after treatment are identical . EffectiPatients with HG-BE receive endomucosal resection (aimed at removing dysplasia) then enter the surveillance program, undergoing surveillance endoscopy every six months. Patients with EAC undergo cancer treatment, followed by surveillance endoscopy every six months. Patients with ND-BE and LG-BE do not receive any resection, but undergo surveillance endoscopy every 36 months and six months, respectively, according to the BSG recommendations on diagnosis and management of BE .The decision tree used to schematise the diagnostic and surveillance phases of the analysis is shown in Outputs from a literature review (conducted in May 2017) were used to identify relevant clinical inputs for the model. Four predefined Population, Intervention, Comparator, and Outcome (PICO) scenarios were queried in the search to address four key research questions: Q1) What is the epidemiological burden and prognosis associated with BE?; Q2) What is the key evidence  associated with NBI or other alternative techniques in the diagnosis and treatment of BE?; Q3) What is the comparative sensitivity, specificity, treatment effectiveness of NBI vs alternative techniques?; Q4) What are the main economic implications of BE management with NBI  in the diagnosis / treatment of BE?A literature review was conducted using both EMBASE and PubMed / MEDLINE databases. Search limits were applied, including articles: i) in English language only; ii) humans only; iii) published since 2005 ; iv) evaluating diagnostic accuracy in BE, esophageal neoplasia, esophageal dysplasia, EAC; analysing disease incidence, prevalence, survival, progression rates, other relevant patient outcomes. Articles were excluded if they were not original articles . Search terms used to conduct the review are reported in Of the 2,106 articles retrieved, 658 passed the first screen, and 285 were included for data extraction . Table 1A range of intervention-specific and non-specific clinical and cost inputs were used in the model and sourced from the published literature, NHS Reference Costs, and Olympus data on file see . Both coThe base-case analysis was conducted adopting the NHS England perspective and a time horizon of 7 years. In this analysis, the diagnostic performance of NBI and HD-WLE was based on per-patient level data, according to which NBI has the same dysplasia detection rate as an HD-WLE examination with the Seattle protocol, while requiring fewer biopsies .The base-case considers that more than 160,000 patients with known or suspected BE undergo an endoscopic test in England and that this number is rapidly growing at a rate of 20% every year  are equipped to conduct Barrett’s Esophagus surveillance endoscopy ; an averA range of analyses were conducted to inform on various analysis settings. On top of the base-case, five additional analyses were run by varying the following parameters: i) dysplasia diagnostic effectiveness (measured using per-patient data or per-lesion data); ii) perspective ; iii) patient follow-up .In the hospital perspective, a micro-costing approach is used for calculation of endoscopic costs. The model defaults to assuming all resources are included as a cost with the exception of tariffs for endoscopy and treatment (i.e. EMR+RFA) which are included as reimbursements and thus considered income. In the NHS perspective, a micro-costing + tariff approach is used for calculation of endoscopic costs. The model defaults to assuming scopes and systems are direct costs to the NHS, in addition to the cost of tariffs for endoscopy and treatment; all other cost items are not applicable as they are covered under tariff. The number N = 649 corresponds to the estimated number of patients with known BE attending endoscopy in each UK hospital which is equipped to conduct BE surveillance.A deterministic, one-way sensitivity analysis (OWSA) was conducted on the results of the base-case cost-consequence analysis to quantify any uncertainty in results. Input data tested included demographics , efficacy and safety , and costs . The lower and upper limits of all inputs were relative variations of ±10%, except for discounting costs  and diagnostic accuracy . One adIn the budget impact analysis, the estimated annual savings were shown to increase each year as the population attending for surveillance endoscopy continued to grow . By yearCost-effectiveness analysis was not applicable in the base-case analysis as it was assumed that NBI and HD-WLE had the same diagnostic performance based on per-patient sensitivity and specificity. This conservative approach was adopted in order not to overstate the benefit of NBI, considering that: i) the primary evidence used in the model from Sharma et al  concludeResults of alternative scenarios in the NHS or hospital perspective are summarized in OWSA confirmed robustness of the base-case analysis findings . Cost-saBE is a common condition, characterized by negative impact on patient prognosis and quality of life, plus significant economic burden for healthcare services. According to epidemiology estimates, there are at least 160,000 patients with BE in England . This nuThe annual budget impact associated with BE is significant. In our analysis, per-patient costs and Year-1 budget impact  were approximately £1,340 and £216 mln, respectively . Two comOur literature review confirms this hypothesis: recent meta-analyses from renowned scientific associations  have endNevertheless, given the developments in this therapeutic area, regular surveillance of the literature is strongly recommended to ensure the most recent and appropriate sources are captured in the economic analysis.Although every effort was made to ensure robustness of the model and its results, the economic model has several limitations. First, due to the lack of clear data regarding the annual number of esophageal procedures executed by NHS England, estimates on the number of BE patients were based on epidemiological calculations . This approach was adopted since NHS reports grouped esophageal procedures together with those involving the upper gastro-intestinal tract. For this reason, it was not possible to determine the number of esophageal procedures from NHS activity reports. Conservatively, we adopted low-end estimates for BE prevalence and applied an arbitrary reduction factor of 25% to take into account that BE might be under-diagnosed. As a result, budget impact estimates in the first years of analysis could have been underestimated. Regardless, conclusions of the cost-consequence analysis (i.e. NBI cost saving vs HD-WLE) would not be affected by such underestimation, thus maintaining validity.Second, we assumed no difference in detection rates between NBI and WLE, which may not be reflective of real-life clinical practice. This assumption was based on a single study , but wasMoreover, there was uncertainty regarding the level of adherence to the Seattle Protocol, which may not be universally followed by endoscopists ,42. AlthThird, there were limitations around reliability in some of cost inputs incorporated. While remuneration items  should realistically reflect the economic expenditure for NHS England, costs of histological exams might be affected by some variability  were sourced from internal market data and may not, therefore, entirely reflect current market trends. However, the uncertainty associated with resource consumption and unit cost assumptions was tested through sensitivity analysis, which confirmed findings of the base-case analysis.The results of our model suggest that NBI with targeted biopsies is a cost-saving strategy for NHS England compared to current practice, i.e. HD-WLE with random biopsies, for the detection of dysplasia in patients with BE, and may ensure at least comparable health outcomes for patients. However, since the constant evolution of diagnostic techniques will likely determine further improvements in the diagnosis and treatment of BE, it is highly recommended to review and update the available evidence, and conduct analyses reflecting such developments, including the selection of new comparators.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


With the increase of the statutory retirement age, the number of self-employed older workers will most likely increase. Therefore, this study aimed to explore: 1) the differences in self-rated health and work ability of self-employed workers and employees, 1) whether self-employment is associated with better self-rated health and work ability across three years, than employment, and 3) the role of sociodemographic, health- and work-related characteristics  in these relationships.Data was used from the Study on Transitions in Employment, Ability and Motivation, where self-employed  and employees  aged 45–64 years were followed during 2010–2013. Linear regression and generalized estimating equations analyses were carried out to study the differences in self-rated health and work ability  of self-employed and employees. To explore the role of sociodemographic, health-and work-related characteristics in these associations, we included interaction terms between these characteristics and employment status.The self-employed had better work ability (8.3 versus 8.2), and better self-rated health (3.4 versus 3.3) than employees. Work ability of self-employed improved over time, compared to the changes over time in work ability among employees, but not no difference in change over time in self-rated health was found. None of the interaction terms were statistically significant (p>0.05).We observed higher scores in self-rated health and work ability among the self-employed than employees. Being self-employed leads to an increase in work ability across three years. The differences in work ability can be considered small, and more research is needed to establish the role of self-employment as a potential facilitator for sustainable employment. In many European countries, a considerable proportion of the total working population is self-employed, for example, 16 per cent among European workers, and 17 per cent among Dutch workers . AlthougThe self-employed differ from employees with regards to the working conditions. The self-employed have greater autonomy (i.e. job control), more flexibility in working hours and work pace compared to employees , 5. ThesIn recent years, there has been an increasing interest in studying the effect of employment status on self-rated health and work ability among the total working population , 14–16. However, it is unknown whether this also accounts for the older working population. Previous studies have shown the moderating role of certain socio-demographic factors , work characteristics (related to job control and job demands), and the presence of a chronic disease –24. TherIn this study, we aimed to explore among older workers: 1) the differences in self-rated health and work ability of self-employed workers and employees, 2) whether self-employment is associated to better self-rated health and work ability across three years, compared to employment, and 3) the role of sociodemographic, health- and work-related characteristics in these relationships.The present study used a prospective design, and followed STROBE guidelines . Data weThe Medical Ethical Committee of VU University Medical Center Amsterdam declared that the Medical Research Involving Human Subjects Act does not apply to STREAM. The Medical Ethical Committee had no objection to the execution of this study. In the information for participants that accompanied the online questionnaires, it was emphasized that the privacy of participants was guaranteed, all answers to the questions were treated confidentially, and all data were stored in secured computer systems. By filling in the questionnaire, participants implicitly gave permission for the use of the data. All data were fully anonymized before accessing the data.Work ability was assessed using the first dimension of the Work Ability Index (WAI), in which workers estimate their current work ability compared to the lifetime best (0 not able to work– 10 lifetime best). Previous studies have shown that this single question item is highly associated with the overall WAI –30. SelfThe independent variable was self-reported employment status, operationalised as self-employed or employee (full time or part time). Participants who reported to be self-employed as well as employee, were grouped in the type of employment based on where they worked most hours.The covariates were: level of education, financial situation, chronic disease, and work characteristics. Level of education was categorized as: 1) low , 2) intermediate , and 3) high . Financial situation was measured using the following question: ‘What is the financial situation of your household now?’. This variable was dichotomized into 0) those who said to have ‘some money left/a lot of money left’ and 1) those who said to be ‘very or somewhat short of money’. The presence of a chronic disease was determined by asking whether they had one of the following chronic diseases: hands, arms, legs, feet or back and neck symptoms; migraine or severe headache; cardiovascular diseases; asthma, bronchitis, emphysema; gastrointestinal disorders; diabetes; severe skin disease; psychological complaints; hearing problems; epilepsy; life-threatening disease (e.g. cancer); problems with vision; or other longstanding diseases. This variable was dichotomized into 0) those who answered ‘none’, and 1) those who had at least one of the listed chronic diseases.The work characteristics were: mental load (high vs. low), physical load (high vs. low), and autonomy (low vs. high). Mental load was assessed using three items based on whether work activities require intensive thinking, thoughts and attention . PhysicaDescriptive statistics  were used to report baseline characteristics of the self-employed and employees in 2010–2013. Independent t-test and Pearson Chi-square test were used to report differences between self-employed and employees (significance at p<0.05).Linear regression analyses were performed to study the differences in self-rated health and work ability of self-employed and employees using only information from baseline data in 2010, adjusted for age, sex, combined employment status, educational level, chronic disease, financial situation, mental load, and physical load.Generalized estimating equations analyses (GEE) were carried out to study whether self-employment is related to better self-rated health and work ability across three years (2010–2013), compared to employment, adjusted for age, sex, combined employment status, educational level, chronic disease, financial situation, mental load, and physical load , 37. TheTo explore the role of sociodemographic, health- and work-related characteristics for these relationships, interaction terms between low educational level, poor financial situation, presence of chronic disease, and poor work characteristics  and the independent variable were separately added in the second step to the adjusted models. Multiplicative interaction was considered statistically significant if the interaction term showed a p-value below 0.05. For the categorical variable , it was considered statistically significant if the overall interaction term showed a p-value below 0.05.In addition, additive interaction was studied. In general, additive interaction is relevant from a public health perspective; however, sometimes the multiplicative scale may be the one more naturally corresponding to biological mechanism, 43. TheUsing the same GEE model, a complete case analysis, and a subgroup analysis among individuals only with good self-rated health or good work ability at baseline were performed to study the relation between employment status and self-rated health or work ability across three years 2011–2013.All statistical analyses were conducted with SPSS Statistics (version 22).The baseline characteristics of the self-employed and employees are presented in The analyses showed that employment status was statistically significantly associated with self-rated health and work ability, indicating that the self-employed reported higher self-rated health and work ability than employees in 2010 , but not for self-rated health . Among individuals with good self-rated health at baseline, significant results were found for work ability , but not for self-rated health . Similarly, among individuals with good work ability at baseline, significant results were found for work ability , but not for self-rated health .Firstly, we found that, among older workers, self-employed workers had better self-rated health and work ability compared to employees. Secondly, the work ability of self-employed workers statistically significantly improved over time compared to the changes in work ability among employees, while no difference over time was observed in self-rated health between the two groups. Thirdly, sociodemographic , health (presence of a chronic disease) and work-related characteristics  did not modify these relationships.We found evidence that self-employed workers had higher work ability scores, both at baseline as well as over time, than employees. This positive effect of being self-employed on work ability is explained by considerably higher levels of autonomy reported by self-employed workers in the present study, since our post hoc analysis (data from 2010) showed that adjustment for autonomy attenuated the relation between employment status and work ability with 68%. In line with previous studies, the present study showed that the self-employed have a better self-rated health compared to employees , 16. A pOur results with regard to the positive findings on work ability could be explained by two mechanisms: 1) older workers with better work ability are more likely to become self-employed, and 2) self-employment can positively influence the work ability of older workers leading to sustainable employment . Since wFurthermore, it might be possible that in our study, the general population of workers  aged 45 years and older at baseline consists of relative healthy older workers for two reasons: (1) participation in paid work requires good health, especially at older ages, and (2) those in poor health have the tendency to leave employment [Strengths of this study include the availability of a large sample of self-employed and employees and the use of a follow-up period of three years. Some limitations should also be taken into consideration. Among the respondents with missing data, the self-employed workers had a higher work ability score compared to the employees see . HoweverThe rapidly ageing workforce puts a pressure on policymakers to pay attention to keeping the workforce and especially the older workers healthy. Our results suggest that being self-employed might have a positive influence on work ability over time among older workers. Nevertheless, the difference in the work ability score is considered to be small. Further research is required to establish more definitive answers in the role of self-employment as a facilitator for sustainable employment. Furthermore, we underline the importance of taking into account a possible self-selection of older workers with better work ability into self-employment in future studies by identifying  factors related to the transition into self-employment.Since good self-rated health and high work ability are important factors for employment, there is a need for interventions that are effective in stimulating a healthy and productive working life for older workers , 48. SinWe showed that the self-employed had better self-rated health and work ability than employees. Furthermore, self-employment was significantly associated with positive changes over time in work ability compared to the changes over time in work ability among employees. However, the difference in work ability was small, and more research is needed to establish the role of self-employment as a potential facilitator for sustainable employment.S1 Table(DOCX)Click here for additional data file.


Introduction: Driving an automobile is an important activity for the social participation of individuals with traumatic brain injury (TBI). Return to safe driving is usually addressed during rehabilitation, but we know little about driving behaviors in the years following TBI rehabilitation.Objective: To explore self-reported and objective  post-rehabilitation driving behaviors and offenses in individuals with TBI: (a) having passed a driving evaluation, (b) who did not undergo a driving evaluation, and (c) non-injured controls.Methods: Cross-sectional design with 162 adults: (a) 48 participants with mild, moderate, or severe TBI whose drivers' license was suspended and reinstated following a driving evaluation during rehabilitation ; (b) 24 participants with TBI who maintained their driving privileges without undergoing a driving evaluation ; (c) 90 non-injured controls . Participants with TBI were recruited from seven rehabilitation centers, 2–3 years after the end of rehabilitation in the province of Quebec, Canada. During a telephone interview, data were obtained regarding self-reported driving: (a) habits; (b) self-efficacy; (c) anger expression; (d) sensation-seeking; (e) violations/errors; (f) accidents, driving offenses, and demerit points for the two-year interval predating the study. Objective data for driving offenses, accidents, and demerit points were obtained from the automobile regulatory body for the same period and for the two-year interval before the injury for the TBI groups.Results: Compared to non-injured controls, the TBI-DE group reported significantly lower scores for self-reported verbal aggressive expression of anger and driving violations/errors. Conversely, their official driving records showed significantly more demerit points for the last 2 years, and a significantly higher frequency of serious post-rehabilitation accidents (10), compared to the TBI-NE group (one) and the control group (none). Compared to pre-injury levels, individuals with TBI had significantly more demerit points post-rehabilitation.Conclusions: Individuals with TBI may underestimate risky driving behaviors even if they have been deemed fit to drive. Reduced self-awareness, memory, and dysexecutive problems following TBI could influence self-report of driving behaviors and explain discrepancies between self-reported and objective driving-related behaviors. Recommendations for research and practice are provided. Traumatic brain injury (TBI) is a worldwide health problem resulting in long-lasting disability and negative psychosocial consequences, even in individuals with milder injuries . SuccessRegarding the time necessary to return to driving, the results of a multicenter study indicated that 42% of individuals with TBI had returned to driving 1 year post-injury and the percentage increased to 53% at 5 years post-TBI . Even whDriving can be an automatic and over-learned activity for experienced drivers, but it is far from being a routine activity because cognitive functions are necessary to effectively respond to changing environments and the continuing flood of complex information , 16. CogHowever, there are relatively few studies investigating driving behaviors in individuals who have returned to driving following a TBI with discordant findings. For example, the results of a study aiming to determine the frequency of road traffic accidents in 60 adults following severe TBI indicated that although 50% resumed driving, 63% of them were involved in traffic accidents with personal responsibility in 26/36 accidents . The autIn contrast, a recent meta-analysis including eight studies published between 1990 and 2015 indicated that there were no significant differences between individuals with TBI and non-injured individuals in the objective risk of motor vehicle collisions . This meThe current study thus aimed to explore self-reported and objective  driving behaviors and offenses in a group of: (a) individuals with TBI, 2–3 years after the end of rehabilitation, who had been evaluated for driving ability following their TBI and deemed fit to return to driving (TBI-DE); (b) individuals with TBI, 2–3 years post-rehabilitation, who had continued to drive following their TBI and did not require a driving evaluation (TBI-NE); and (c) non-injured drivers from the general population. The main objectives were to: (a) compare self-reported driving behaviors and road offenses  between the three groups of participants; (b) compare data from official driving records  between the three groups of participants; (c) compare pre-injury and post-rehabilitation data from official driving records  explore the relationship between self-reported driving behaviors, and number of accidents and offenses in driving records of participants with TBI post-rehabilitation.This study was conducted within a publicly funded and universally accessible TBI continuum of care. When needed, comprehensive person-centered interdisciplinary neurorehabilitation is freely available to individuals with TBI. Furthermore, the driving license of an individual with TBI is systematically suspended when indicated by the medical and rehabilitation staff. Within the continuum of care, individuals with TBI are referred to one of the driving evaluation programs in the rehabilitation centers for an evidence-based formal assessment of driving fitness. As such, this is a rehabilitation context with equality of access and systematic referral for evaluation of driving fitness. Given the context of unequal access to rehabilitation in which most of the previous studies have been conducted, the discordant results could be in part due to differential access to neurorehabilitation and driving evaluation services. Based on this context permeating our hypotheses, we anticipated that the TBI-DE group would mainly comprise individuals with moderate to severe TBI. Considering the previously highlighted long-term post-TBI cognitive and behavioral issues affecting driving that often persist even following neurorehabilitation, we hypothesized that the TBI-DE group, but not the TBI-NE group, would present more objective road accidents and offenses in the last 2 years  compared to non-injured controls, but that their self-reported driving behaviors  would be similar to those of the other two groups. Given the discordant findings in the literature, we did not anticipate any hypotheses for objectives c and d given their exploratory nature.A total of 162 participants took part in this study, including a convenience sample of 72 adults with TBI, and 90 non-injured controls. Participants with TBI were recruited from TBI rehabilitation programs in seven different neurorehabilitation centers across Quebec, Canada. The TBI-DE group consisted of 48 adults whose license had been suspended after the injury  and reinstated following a driving evaluation during outpatient rehabilitation. The TBI-NE group included 24 adults with TBI who had maintained their driving privileges without undergoing a driving evaluation. Non-injured controls included 90 adults without any diagnosed neurological or psychiatric disorder.Participants with TBI were recruited based on the following inclusion criteria: (a) adults having received a diagnosis of TBI, according to the TBI guidelines put forward by the Quebec Ministry of Health , with a CIUSSS du Centre-Sud-de-l'Île-de-Montréal (CIUSSS CSMTL) approved the current study. Recruitment took place between September 2013 and March 2016. Participants with TBI were recruited from seven rehabilitation centers in the province of Quebec providing driving evaluation programs for individuals with motor, perceptual, or cognitive disabilities. These programs offer fitness to drive assessments, driving skills training, and vehicle adaptation services to individuals referred from other programs within the rehabilitation centers or from outside sources. Research coordinators from the rehabilitation centers contacted potential participants with TBI (TBI-DE and TBI-NE groups) who had finished their rehabilitation program between September 2010 and March 2013  and invited them to participate in the study. Non-injured controls from the community were recruited by the professional external interview agency that conducted the interviews. A financial compensation of 15$CAD was provided to all participants.The Research Ethics Board (REB) of the Center for Interdisciplinary Research in Rehabilitation of Greater Montreal of the Société d'Assurance Automobile du Québec-SAAQ), and medical records. Participants provided informed consent to participate in the study and could also accept or deny access to their driving records. Access to medical records of participants with TBI also required informed consent. Telephone interviews were conducted by a professional external interview agency . During the telephone interview, non-injured controls and participants with TBI provided information  for the previous 2 years  regarding their driving habits , as well as the number of road accidents, number of driving offenses, and demerit points. Objective data for road accidents, the seriousness of accidents , driving offenses and demerit points were also obtained from participants' official driving records for the previous 2 years for all participants , as well as for the 2 years preceding injury in the TBI groups. In the province of Quebec, demerit point brackets are determined on the basis of the type of license, where a four-point bracket applies to holders of a learner's license or those who have held their license for fewer than 5 years, and 8-, 12-, and 15-point bracket apply, respectively to driver's license holders under age 23, aged 23 or 24, or aged 25 or older . During the telephone interview, self-reported driving behaviors were measured for all participants using the following outcome measures.Data were gathered using a semi-structured telephone interview conceived by the research team, records from the Automobile Insurance Board of Quebec , and driving behaviors . Chi-square or Fisher's exact tests were computed to evaluate differences in sex, TBI severity, type of route taken, and seriousness of accidents  between the three groups. Paired-samples t-tests were calculated to compare pre-injury and post-rehabilitation official records of number of accidents, driving offenses, and demerit points in participants with TBI. Pearson product-moment correlation coefficients were calculated to examine, for the past 2 years in participants with TBI , the relationships between self-reported driving behaviors, and objective number of accidents and driving offenses. Correlation coefficients were interpreted using the following guidelines for the behavioral sciences (r = 0.1–0.29), (b) medium (r = 0.3–0.49), and (c) large (r = 0.5–1). Statistical significance was set at an alpha level of 0.05.Statistical analyses were conducted with IBM SPSS® version 25 . Descripsciences : (a) smaF = 4.01, p = 0.02. The effect size (eta squared) was small, at 0.04. Post-hoc comparisons indicated that the TBI-NE group was younger than the control group. There were no statistically significant differences in age between the TBI groups or between the TBI-DE group and the control group. Regarding injury severity, the TBI-DE group had more participants with moderate and severe injuries (72.9%) than the TBI-NE group, which comprised mainly individuals with mild injuries (75%), X2  = 16.52, p = 0.0003.As indicated in F = 6.98, p = 0.001. The effect size (eta squared) was medium, at 0.08. Post-hoc comparisons indicated that the TBI-NE group had significantly fewer months of driving experience as compared to the TBI-DE group and the control group. There were no significant differences between the TBI-DE and the control group in months of driving experience. There were no significant group differences in kilometers traveled per year. Preferred traveling distances in terms of routes taken were also similar in the three groups, with distances between 10 and 50 km being the most frequently driven. Compared to participants with TBI, the non-injured control group was less likely to authorize access to their driving records, X2  = 32.71, p = 0.00001.In terms of driving habits, there was a statistically significant difference in months of driving experience between the three groups, Post-hoc comparisons indicated significantly lower mean scores for verbal aggressive expression of anger in the TBI-DE group compared to the control group. Mean scores for the verbal aggressive expression of anger were comparable between the TBI-DE and the TBI-NE groups, and between the TBI-NE and the control group. In addition, there was a statistically significant main effect, with a small effect size, for driving violations/errors (DBQ). Post-hoc tests showed that the TBI-DE group reported significantly fewer driving violations/errors than the TBI-NE group, but there were no statistically significant differences between each of the TBI groups and non-injured controls.As shown in Post-hoc analyses indicated that the TBI-DE group had significantly more demerit points compared to non-injured controls. The TBI-DE group also showed a tendency, with a medium effect size, toward more driving offenses in the past 2 years, but this difference did not reach statistical significance. There were no significant differences between the TBI groups in pre-injury number of accidents, driving offenses or demerit points documented in driving records.As shown in p = 0.0003, two-tailed). The TBI-DE group had a significantly higher frequency of serious accidents resulting in bodily harm or death in the last 2 years (10 serious accidents with two minor accidents), compared to the TBI-NE group (one serious accident with four minor accidents) and the non-injured control group (no serious accidents with four minor accidents). As for differences in pre-injury seriousness of accidents between the TBI groups as documented in driving records, there was a tendency for a higher frequency of serious accidents in the TBI-DE group (four serious accidents without minor accidents) compared to the TBI-NE group (no serious accidents with two minor accidents) .Fisher exact tests showed a strong significant between-group effect for the seriousness of accidents documented in driving records post-rehabilitation . There were no statistically significant differences between the pre-injury and post-rehabilitation number of accidents or driving offenses for the TBI-DE and TBI-NE groups.Comparison between pre-injury and post-rehabilitation objective data from driving records revealed that for both the TBI-DE, r = −0.39; p < 0.05). Conversely, the TBI-NE group showed strong positive relationships between the level of verbal aggressive expression of anger and the number of accidents , as well as driving offenses . The TBI-NE group also showed a medium, positive relationship between the level of driving-related sensation-seeking (DRSS) and the number of driving offenses , as well as a strong negative association between the level of adaptive/constructive expression of anger  and the number of accidents . There were no statistically significant associations in the TBI-DE group. There were no significant correlations for self-reported driving behaviors with age, injury severity, or driving experience.Pearson product-moment correlation coefficients were calculated between post-TBI rehabilitation (i.e. last 2 years) objective accidents and offenses, and self-reported driving behaviors. In the TBI-DE group, there was a medium, negative association between the level of verbal aggressive expression of anger  and the objective number of accidents  or not having undergone a driving evaluation (TBI-NE), with non-injured drivers from the general population. To our knowledge, this is the first multicenter study comparing self-reported and objective driving behaviors in individuals with TBI with or without a driving evaluation, 2–3 years post-rehabilitation, with a non-injured control group. Results show that compared to the TBI-NE and control groups, the TBI-DE group  showed lower or similar self-reported anger- and error-related driving behaviors 2–3 years post-TBI rehabilitation. In contrast, their official driving records (but not their self-report) indicated the presence of a higher number of demerit points and serious accidents. These findings, which have potentially significant public health implications, are generally in line with our hypotheses, although it was not anticipated that the TBI-DE group would report significantly less driving anger expression or errors in driving behaviors. As expected, the TBI-DE group was comparable to the other groups in terms of self-reported driving self-efficacy, driving-related sensation-seeking, and the use of the vehicle to express anger. Of note, there were no group differences in the number of kilometers driven per year and usual traveling distances, indicating that driving habits were similar in the three groups.Our results suggest that individuals with TBI, in particular those with moderate to severe TBI that have undergone a driving evaluation to get their drivers' licenses reinstated after the injury , may overestimate their driving abilities even though they present more serious accidents and demerit points as documented in driving records. This is further supported by the negative association between self-reported verbal aggressive anger expression and the number of documented accidents post-rehabilitation in this group. That is, participants in the TBI-DE group who reported lower levels of verbal aggressive expression of anger appear to be those who presented more serious accidents. These findings are compatible with a study comparing self-report and motor vehicle records in 47 individuals with TBI who successfully completed a comprehensive driving evaluation and 22 healthy controls . All parn = 12, 54.5%) reported taking part in significantly more unsafe driving situations than the group of individuals with TBI . This difference can possibly be explained by the fact that their sample of individuals with TBI reported driving less than the sample of healthy controls, and since they measured only minor accidents. Another study showed that drivers having been assessed for driving fitness generally reported modifying their driving behaviors and did not report more crashes compared to pre-injury  TBI during a motor vehicle accident. Although this was not an objective of the present study, future research should specifically study the relationships between mechanism of injury and TBI severity, and pre-post TBI driving behaviors as well as road accident/offense history. The literature does suggest that certain groups are more vulnerable to the risk associated with driving. For instance, under different driving conditions, there is a dramatic increase in driving risk among adolescents in the transition period to independent driving . Males , collegeIn sum, individuals with TBI, even though they have passed a driving evaluation, may represent a subgroup that is at risk in driving situations since they rated their driving behaviors as being similar to, or better than, non-injured controls even though they presented more serious accidents and demerit points in their driving records than healthy controls in the community. Furthermore, individuals with TBI who have not been identified as needing a driving evaluation during rehabilitation  may also be at risk for increased road offenses resulting in demerit points in the years following rehabilitation. These original findings bring driving safety following a TBI to the forefront in terms of public health and warrant more systematic processes for insuring safe driving following TBI rehabilitation. Problems with self-awareness and executive functions, often seen in more moderate to severe TBIs , could be at the basis of these findings, as may be post-TBI memory problems in general , 41, 63.Limitations of this study include self-selection and self-reporting bias, the characteristics of the sample, and the research design. Self-selection bias is inherent to these types of studies. Participants who volunteer for studies on driving may generally find themselves safer to drive . In some cases, individuals may decline participation out of fear that their driving license will be suspended or because they are uncomfortable with the study objectives . That coFor administrative reasons, we were not able to document some characteristics including the cause of the TBI, the exact time between the end of rehabilitation and the completion of the telephone interview , and the date of the driving evaluation . In addition, we did not measure cognitive and psychological functioning or self-awareness simultaneously with self-reported driving behaviors since this was not an objective of our study, but these would all be important aspects to address in future studies. Finally, a cross-sectional study cannot fully capture the temporal evolution of driving behaviors, and longitudinal studies are warranted to track changes in driving behaviors over time following a TBI.In this study participants with TBI having passed a driving evaluation resumed driving at the same level as participants with TBI who did not undergo a driving evaluation and as non-injured controls, but they appeared to underestimate their risky driving behaviors. Self-awareness concerning driving skills should be fully assessed during off- and on-road assessment of driving fitness during rehabilitation –66. ClosThe finding that compared to pre-injury levels, individuals with TBI had significantly more demerit points post-rehabilitation compared to their pre-injury driving records has important public health implications. We recommend that during rehabilitation individuals with TBI be closely monitored regarding abilities and behaviors related to driving skills. Prevention measures such as mandatory training to increase their driving abilities as well as awareness of risks for road accidents and driving sanctions if they transgress road safety rules, could be systematically implemented even in individuals with TBI who have successfully undergone a driving evaluation process.As suggested by Deffenbacher et al. , interveTo date, there are no single measures or a combination of measures that will accurately predict who is and who is not a safe driver following a TBI . As suchWhen available, driving simulators are a controlled and repeatable strategy to measure driver behaviors . HoweverRestricted licensing offers an alternative to license withdrawal in many North American jurisdictions and in Australia to help individuals in the transition to independent and safe driving allowing them to drive only under certain conditions , but more evidence is needed in the context of TBI .Based on the results of the current study, the critical review of the literature, and our clinical experience in different rehabilitation fields and more broadly in driving psychology, some clinical and policy recommendations are proposed:MM, PD, and IG designed the study and conducted data collection. AM and MM conducted statistical analyses and drafted the manuscript. All authors reviewed the different iterations of the manuscript and approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The ever-increasing high-volume and high-dimensional genomics data on the one hand challenge traditional data analysis approaches, and on the other hand provide ample opportunities for developing novel analytic strategies. In recent years, deep learning has been driving the next wave of artificial intelligence and machine learning. Now, Yi Xing’s lab reported DARTS cis-elements around the splicing site in both exonic and intronic regions, and trans-acting factors that bind to specific cis-elements. It has been shown that AS plays critical roles in a variety of physio-pathological processes.In higher eukaryotes, the vast majority of protein-coding genes are transcribed into precursor mRNA (pre-mRNA) containing exons and introns that need to be removed by the splicing machinery to generate mature mRNA. Often the transcript can be spliced in different ways, leading to a different combination of exons. AS contributes to the variety of the cellular proteome as well as to the fine tuning of gene expression levels at the post-transcriptional level. The regulation of AS is mediated by the interaction between vs. disease, as well as control vs. treatment. For the latter, many computational methods have been developed. The common strategy underlying these methods is to use the number of RNA-seq reads exclusively supporting either isoform to estimate an abundance ratio between the two spliced isoforms, i.e., inclusion and exclusion isoform, and then perform a statistical test to determine whether the splicing pattern between the two samples is significantly different or not. Although implemented with different statistical frameworks, all these methods would encounter high uncertainty for the splicing events sampled with low sequencing coverage. Therefore, the sensitivity is rather limited in detecting differential AS for the lowly-expressed genes. Moreover, many currently available RNA-seq datasets originally designed only for differential analysis of gene expression are often of low sequencing depth, which is insufficient for AS analysis even for moderately-expressed genes. Harnessing these valuable resources for AS studies warrants novel analytic strategies.In the last decade, the amount of RNA-seq data has soared, which provides valuable resources for extensive studies of transcriptional and post-transcriptional regulation. In addition to providing the information on RNA abundance, RNA-seq data could also be used to infer the AS pattern, and more often to identify the differential AS between different samples, such as those from different developmental stages, normal e.g., image recognition and language processing) with great success. Unlike the traditional machine learning algorithms, deep learning trains both the feature extractor and the classifier simultaneously. The high model complexity caused by the extraordinarily large number of parameters makes deep learning models data-hungry. Such high model flexibility, on the other hand, together with the powerful optimization algorithms, enables deep learning to achieve the state-of-the-art performance on a wide spectrum of applications where large datasets are available, such as computer vision, natural language processing, and genomics.Deep learning has recently reemerged in various fields  to estimate the prior probability and a likelihood estimator (DARTS BHT) based on the prior probability as well as RNA-seq read counts. Before training DARTS DNN, large-scale RNA-seq data are analyzed first by DARTS BHT with uninformative prior to generate a high-confidence labeled training dataset that contains both differential splicing and unchanged splicing between conditions. Then the labeled training dataset is used for training DARTS DNN. In contrast to the aforementioned deep learning-based AS methods, this deep learning module incorporates not only the cis-elements from the primary genomic sequences but also the trans-elements represented by the expression level of 1498 splicing-relevant RBPs. Zhang et al. first evaluated the performance of DARTS on the test data corresponding to leave-out RBPs and showed that DARTS outperformed the baseline methods. They then applied DARTS on two cell lines to infer cell-type-specific splicing events, in which they found that the performance of DARTS BHT with an informative prior probability is better than that without the prior, demonstrating that incorporating DNN prediction as an informative prior improves the performance of DARTS BHT in detecting differential splicing. To further demonstrate the power of DARTS DNN on other RNA-seq datasets, they trained three DARTS DNN models using ENCODE data only, Roadmap data only, and their combination, respectively. They found that the model trained on ENCODE data has high predictive power for the ENCODE leave-out datasets, but modest predictive power for Roadmap leave-out datasets, and vice versa, while the model trained on the combination of both datasets has the best performance. Furthermore, they extended DARTS DNN to other types of AS events, i.e., alternative 5′ or 3′ splice sites and retained introns, and they also achieved a high prediction accuracy. Finally, they applied DARTS to investigate the change of AS pattern during the epithelial-mesenchymal transition (EMT) using the previously published RNA-seq dataset The new tool, DARTS, mainly consists of two components, a prior based on learned knowledge about each AS event in a specific sample, while the latter further integrates the information from RNA-seq data. (2) The deep learning model within DARTS framework for the first time takes both cis-elements and trans-factors into consideration, which improves differential AS detection between conditions.The major innovation of DARTS lies in two aspects. (1) DARTS combines a deep learning model with Bayes hierarchical framework: the former provides the latter cis–trans interactions, such association requires a prohibitively large number of input combinations. Second, DARTS is trained on invariant genomic sequences from different samples, and thus could not capture the splicing landscape of sequence variants. Third, the performance of DARTS may be further improved by incorporating increased lengths of flanking regions or more cis-features. However, it requires more data and sophisticated feature engineering to obtain a better model.There are yet some directions for further development of DARTS. First, although DARTS can theoretically capture the cis–trans interaction. Therefore, APA regulation could be treated as a similar problem and accordingly investigated with a similar strategy. Xia et al. recently developed a robust, poly(A) signal (PAS) motif-agnostic, and transferable deep learning model to differentiate true PASs from false ones Other than AS, alternative polyadenylation (APA) is also a key, but less-well studied step in RNA processing. And conceptually, similar to AS, the regulation of APA is also mediated by The authors have declared no competing interests.


Previous studies have suggested that peripheral venous catheter is a significant source of gram-negative bacteraemia in patients with malignancy. We aimed to identify risk factors and develop a clinical prediction rule for the involvement of gram-negative organisms in peripheral venous catheter-associated bloodstream infections (PVC-BSIs) among patients with malignancy.This retrospective cohort study was conducted at a 700-bed cancer hospital in Japan. Consecutive patients diagnosed with PVC-BSI based on clinical and microbiological criteria were included in this study. Based on clinical and microbiological characteristics of PVC-BSIs in cancer patients, a logistic regression model for predicting gram-negative organisms as causative organisms in PVC-BSIs was then developed.Of the 99 patients included in our cohort, 60 patients (60.6%) had gram-negative PVC-BSIs. The median age of patients with PVC-BSIs was 67 years , and the median Pitt bactearemia score was 1 . The median duration of catherization was 5 days  and 70 patients (70.7%) received peripheral parenteral nutrition that contained amino acids. On multivariable analysis, age ≥65 years , showering , Pitt bacteraemia score ≥2 points , and use of peripheral parenteral nutrition  were independent predictors for gram-negative PVC-BSIs among all PVC-BSIs. The simplified PVC-GN scores established to predict gram-negative PVC-BSIs had a optimism-corrected c-index of 0.775.Gram-negative bacteria were more commonly responsible for PVC-BSI than Gram-positive bacteria among cancer patients in this cohort. Involvement of Gram-negative bacteria in PVC-BSIs could be predicted with readily available clinical variables. Mortality rates of bloodstream infections in patients with malignancy are significantly higher than in patients without malignancy . The mosThe incidence rates of hospital-acquired gram-negative bacteremia are increasing in recent years, as has been shown in a multicenter study in France and in a national study in Switzerland , 4. SimiWhile central line-associated bloodstream infections have become an important metric in assessing patient safety, peripheral intravenous catheters (PVCs) remains undereappreciated as an intravascular device that is also responsible for catheter-associated bloodstream infections. Compared with central venous catheters (CVCs), the risk per catheter-day of PVC-associated bloodstream infection is lower. However, the large majority of catheters placed in hospitalized patients are PVCs rather than CVCs . As a reStaphylococcus aureus bacteremia [Previous studies of PVC-associated bloodstream infections mainly focused on cteremia , 9. Althcteremia , 11, thecteremia .The purpose of this study was to investigate the clinical and microbiological characteristics of PVC-associated bloodstream infections among patients with malignancies and to evaluate the risk and predictive factors for involvement of gram-negative bacteria.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee  and and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Specific informed consent for this retrospective and non-invasive study was not required by local ethics committee of Cancer Institute Hospital of Japanese Foundation For Cancer Research.We performed a retrospective cohort study to determine the risk factors for PVC-associated gram-negative bloodstream infections at Cancer Institute Hospital of Japanese Foundation For Cancer Research, a 700-bed hospital dedicated to care of patients with malignancies in Tokyo, Japan, between April, 2012 and September, 2017. At this hospital, one of the attending physicians of the department of infectious diseases  evaluated all hospitalized patients who had positive blood cultures during this period by reviewing the medical records and examining the patients as needed as part of standard of care. Our study complied with the TRIPOD  statement regarding the reporting of the study .Consecutive patients were enrolled in this study if they had PVC-associated bloodstream infections diagnosed with criteria as follows, from patients with positive blood cultures for the duration of the study. Only the index episode of PVC-associated bloodstream infection was included for patients with multiple episodes during study period. Cases of PVC-associated bloodstream infections attributable to PVCs inserted before the admission of the hospital were excluded.PVC-associated bloodstream infections were diagnosed according to following three definitions: “definite”, when the same organism grew from a blood culture and a catheter tip culture; “probable”, when a clinically significant positive blood culture was associated with phlebitis defined by the presence of swelling, erythema, tenderness, or pain at the catheter insertion site and absence of alternative sources of bloodstream infection; “possible”, when a clinically significant positive blood culture was not associated with a positive tip culture or phlebitis but apparent sources of bloodstream infection other than the PVC was absent. Septic thrombophlebitis was defined as “definite” if a) an intraluminal thrombus was visualized and either b) the vein was non-compressible or c) an abnormal flow pattern was present in the vessel by sonogram, and as “possible”, if any of a), b), or c) was present , 15.Corynebacterium spp. not C. diphtheria), Bacillus spp. (not B. anthracis), Propionibacterium spp., coagulase-negative staphylococci (including Staphylococcus epidermidis), viridans group streptococci, Aerococcus spp. Micrococcus spp. and Rhodococcus spp.) were diagnosed only when these bacteria were isolated from two or more separate blood cultures [Bloodstream infections by commensal bacteria (cultures . All bacThe adequacy of the diagnosis in daily practice was confirmed by an investigator with expertise in infectious disease (T.S.) by reviewing the medical records of the patients.9/L), pathogen of PVC-associated bloodstream infections, the presence of phlebitis, the presence of septic thrombophlebitis, duration of catherization until the onset of PVC-associated bloodstream infections, infusion of peripheral parenteral nutrition which contain amino acids, fat emulsion, and ≥500 mL fluid from the PVC on the day or the day before the index blood culture, duration of antibiotic therapy for PVC-associated bloodstream infections, time between index blood culture and initiation of appropriate therapy, showering within the week before the index blood culture, results of follow-up blood culture, the presence or absence of persistent bacteremia, duration of fever, complications, and all-cause motality within 30 days of bacteremia onset.The following data were collected from the electronic medical records: age, sex, Carlson comorbidity index , Pitt baA follow-up blood culture was defined as blood cultures that were drawn within 7 days after the day the first positive blood culture was drawn, and after appropriate therapy was started. Persistent bacteremia was defined as the same organism growing from both the index blood culture and a follow-up blood culture collected after appropriate therapy was started. The duration of catherization was defined as the number of days between the day of PVC placement which PVC-associated bloodstream infections was attributed to and the day when the index cultures were drawn. The duration of fever was defined as the number of days between the day of the index blood culture and the day all axillary temperature measurements were below 37.5°C. The duration of therapy was defined as the consecutive number of days at least one active agent was administered.Blood culture was performed with BacT/ALERT 3D system . Catheter tip culture was conducted by overnight incubation of the 3 to 5-cm segment of the catheter tip in Brain Heart Infusion at 36°C. Species identification and antimicrobial susceptibility testing were performed with MicroScan Walkaway . CLSI M100-S22, which was adopted at the hospital during the study period, was used for the identification of methicillin resistance in staphylococci.a priori based on previous studies [We selected age ≥65 years, showering, days of catherization ≥4 days, Pitt bacteremia score ≥2 points, and use of peripheral parenteral nutrition containing amino acids as variables and potential predictors for PVC-associated gram-negative bloodstream infections  studies –21.We calculated the odds ratios and 95% confidence intervals (CIs) by using univariable analysis and multivariable analysis based on logistic regression. We evaluated the model’s discriminative performance by calculating the c-index. The c-index was corrected for optimism to examine internal validity with a bootstrapping procedure using 500 samples drawn with replacement from the original sample . We grapS. aureus , Bacillus sp. (11 cases), S. epidermidis (9 cases), and Pseudomonas aeruginosa (9 cases). Overall, 60 cases (60.6%) were due to gram-negative bacilli.During the study period, there were a total of 2,225 events of positive blood cultures, and 103 of these represented PVC-associated bloodstream infections. Three cases of recurrent PVC-associated bloodstream infections and one episode attributable to a PVC inserted before the admission of the hospital were excluded . Of the Clinical characteristics of the patients with peripheral intravenous catheter-associated bloodstream infections are shown in There were no cases with missing predictor, so we conducted a complete case analysis for a prediction score development. Univariable analysis of age ≥65 years, use of peripheral parenteral nutrition which contained amino acids, showering within the week of index blood culture, days of catherization ≥4 days, and Pitt bacteremia score ≥2 points between PVC-associated gram-negative bloodstream infections and PVC-associated non-gram negative bloodstream infections showed the following odds ratio (OR): age ≥65 years, 1.76 ; use of peripheral parenteral nutrition containing amino acids, 0.48 ; showering within the week before the index blood culture, 2.07 ; days of catherization ≥4 days, 0.48 ; and Pitt bacteremia score ≥2 points, 6.23  .On multivariable analysis, age ≥65 years , showering , and Pitt bacteremia score ≥2 points  were independent risk factors for PVC-associated gram-negative bloodstream infections . Meanwhi-y)  among patients with PVC-associated bloodstream infections. The model had a c-index and an optimism-corrected c-index of 0.795 and 0.753, respectively. From this predictive rule, we generated the following simplified predictive scoring system that can be calculated in the clinic: PVC-GN scores  or quantitative catheter culture techniques  for catheter-associated bloodstream infections which were not available at this hospital during the study period , 33. MorIn conclusion, we found the predominance of gram-negative bacilli as pathogens of PVC-associated bloodstream infections among patients with malignancies and determined the predictive factors of PVC-associated gram-negative bloodstream infections. Further studies, such as multi-center studies or studies including patients without malignancies are needed to assess generalizability of these findings.


Mitochondrial haplogroups characterize branch points in the phylogeny of mtDNA. Several tools exist for mitochondrial haplogroup classification. However, most require full or partial mtDNA sequence which is often cost prohibitive for studies with large sample sizes. The purpose of this study was to develop Hi-MC, a high-throughput method for mitochondrial haplogroup classification that is cost effective and applicable to large sample sizes making mitochondrial analysis more accessible in genetic studies. Using rigorous selection criteria, we defined and validated a custom panel of mtDNA single nucleotide polymorphisms that allows for accurate classification of European, African, and Native American mitochondrial haplogroups at broad resolution with minimal genotyping and cost. We demonstrate that Hi-MC performs well in samples of European, African, and Native American ancestries, and that Hi-MC performs comparably to a commonly used classifier. Implementation as a software package in R enables users to download and run the program locally, grants greater flexibility in the number of samples that can be run, and allows for easy expansion in future revisions. Hi-MC is available in the CRAN repository and the source code is freely available at  Human mitochondrial DNA (mtDNA) consists of a double-stranded, circular chromosome that spans 16,529 base pairs and encodes 22 transfer RNAs, two ribosomal RNAs, and 13 proteins that are part of the oxidative phosphorylation enzyme complexes. Compared with nuclear DNA, unique characteristics of mtDNA include uniparental  inheritance, lack of recombination, high copy number, and a high mutation rate. These characteristics make mtDNA a powerful tool for investigations in multiple disciplines including population and medical genetics, molecular anthropology, and forensics . Strong Mitochondrial haplogroups are collections of similar combinations of mtDNA SNPs inherited from a common ancestor. These haplogroups are formed via the sequential accumulation of mutations through the maternal lineage. As a result of population migration, distinct mitochondrial haplogroups are associated with different continental ancestries including African, European, Native American, Asian, and Oceanic , allowinCurrently, several methods are available for mitochondrial haplogroup classification including Haplogrep2, HaploFind, MitoTool, HmtDB, MToolBox, and Phy-mer . While tUsing a custom panel of mitochondrial SNPs, we constructed a reduced mitochondrial phylogenetic tree, and developed an algorithm (Hi-MC) for broad classification of European, African, and Native American mitochondrial haplogroups. We then genotyped and assigned mitochondrial haplogroups to DNA samples used by the International HapMap Project  . To evalThe algorithm input is a list of mitochondrial SNP genotypes for each individual DNA sample, and the output is haplogroup classification. The revised Cambridge reference sequence is used to specify SNP positions. Phylotree, a comprehensive phylogenetic tree of human mtDNA variation displaying relationships between mitochondrial haplogroups , was useThe algorithm determines the appropriate haplogroup in a two-step process . In the https://github.com/vserch/himc) and is available in the CRAN repository. Data input is standard PED/MAP formatted files. The output is an R dataframe object that includes subject IDs with a corresponding haplogroup classification and the path through the tree from root node to final classification. The output can easily be exported directly to a CSV file or text file. For further details on use of the Hi-MC package in R visit http://www.icompbio.net/resources/software-and-downloads/.The algorithm is implemented as a package in R , Yoruba from Ibadan, Nigeria , Japanese in Tokyo, Japan , and Han Chinese in Beijing, China . The HapMap Phase III samples used in this study included only those of Mexican ancestry from Los Angeles, California . The International HapMap Consortium reported mitochondrial haplogroup classifications for the CEU, YRI, CHB, and JPT Phase I HapMap samples (available at ftp://ftp.ncbi.nlm.nih.gov/hapmap/mtDNA_and_chrY_haplogroups/)  ; howeverhttps://www.coriell.org/1/NHGRI. SNPs were genotyped via the Agena Biosciences (formerly Sequenom) iPLEX® Gold MassArray platform. Multiplex primer extension was performed, and extension products were analyzed by MALDI-TOF mass spectrometry  common in the human genome . The finUsing the genotype data we generated from the custom SNP panel, we employed Hi-MC and Haplogrep2 to determine mitochondrial haplogroup classifications in the PAGE I Study reference HapMap samples. We then compared the Hi-MC mitochondrial haplogroup classifications to the HapMap-reported classifications for Phase I samples  . We alsoAs a final comparison, we accessed the 1,000 Genomes Project mitochondrial data for overlapping DNA samples with the PAGE I Study reference HapMap samples . The 1,000 Genomes Project data were generated by whole genome sequencing , 2012 anftp://ftp.ncbi.nlm.nih.gov/hapmap/mtDNA_and_chrY_haplogroups/) to haplogroups assigned by Hi-MC and Haplogrep2  for CHB/JPT are incorrect.Compared with the CEU and YRI populations, we observed less concordance among the CHB/JPT samples particularly for the Hi-MC- and Haplogrep2-assigned comparisons with HapMap-reported haplogroups . One HapThe mitochondrial haplogroups for the samples of Mexican ancestry from HapMap Phase III (MXL) have not been previously reported. Samples in this dataset include 30 trios of Mexican ancestry from Los Angeles, CA. We applied Hi-MC to determine mitochondrial haplogroups in these samples and characterized the distribution of mitochondrial haplogroups among the MXL. Due to matrilineal inheritance of mtDNA, offspring have the same mitochondrial haplogroup as their mother; therefore, offspring were excluded when calculating the frequency distribution of mitochondrial haplogroups. We also excluded three samples with unclassified haplogroups and two samples with likely incorrectly assigned haplogroups due to missing genotypes, for a total of 55 unrelated MXL samples. Overall in the MXL samples, 89.1% of mitochondrial haplogroups identified were of Native American ancestry and 10.9% were of European ancestry . The disTo further evaluate the performance of Hi-MC, we compared the Hi-MC mitochondrial haplogroup classifications of MXL samples to Haplogrep2-assigned classifications applied to either the custom SNP panel or the 1,000 Genomes Project data. Among the 90 MXL samples, six were unclassified by Hi-MC due to missing data at multiple SNPs. Of the 84 classified MXL samples, there was high agreement between Hi-MC-assigned haplogroups and haplogroups assigned by Haplogrep2 based on the custom SNP panel (97.6%) and the 1,000 Genomes Project data (96.6%). Two MXL samples were misclassified by Hi-MC as haplogroup L3, and both of these samples were missing 11 key SNPs for the Hi-MC classification tree.Using a custom panel of mitochondrial SNPs that we previously applied to participants in the NHANES datasets , we deveMitochondrial SNPs captured by standard genome-wide genotyping arrays vary widely, and often the SNPs on these arrays are not informative for haplogroup determination. Hi-MC uses a defined panel of mitochondrial SNPs for classification of mitochondrial haplogroups eliminating the need for time-consuming SNP selection. Additionally, the relatively small number of SNPs in the custom panel makes Hi-MC particularly useful for large data sets where full mitochondrial genome sequencing is cost-prohibitive. As examples, approaches like Hi-MC promise to be of use to large biobank and cohort efforts such as the Million Veteran Program  and the Hi-MC employs the commonly used PED/MAP file format as the input. There are a number of software programs that make use of the PED/MAP format, including PLINK  which isWe determined that Hi-MC performs well with samples of European, African, and Native American descent. Even though the Hi-MC custom SNP panel was not designed to specifically resolve Asian-specific haplogroups, we present evidence that Hi-MC is comparable to Haplogrep2 in haplogroup assignments for samples of Asian maternal lineage. Compared with other maternal lineages, the Asian branches of the mitochondrial phylogenetic tree are not as well-defined as other parts of the tree despite recent progress made in characterizing the phylogeny of Asian mtDNA . AnotherWe applied Hi-MC to the HapMap Phase III MXL samples as the mitochondrial haplogroups for these participants have not been previously reported. The haplogroup distribution observed in the HapMap Phase III MXL samples is somewhat similar to the recently reported Haplogrep2-generated distribution for the MXL samples sequenced as part of the 1,000 Genomes Project . In thisWhile there are several benefits to Hi-MC, there are some limitations. Currently, Hi-MC employs a reduced mitochondrial phylogenetic tree for classification. As a result, it is currently limited to classification of the major haplogroups of European, African, and Native American lineages, and requires that SNPs from the described custom panel be genotyped. While this panel was customized for populations expected for the PAGE I study, it is notable that several SNPs in this panel  overlap with previously published panels , suggestDespite these limitations, Hi-MC offers several advantages including a defined panel of mitochondrial SNPs that is used in conjunction with the software for mitochondrial haplogroup classification. Hi-MC utilizes PED/MAP files for a user-friendly input file format, saving time and reducing opportunities for errors to be incorporated into the data. Also, Hi-MC is implemented in the commonly used statistical software environment R allowing for classification of relatively large sample sizes, as well as the ability to easily utilize other available R packages for visualization of results.We have developed a custom SNP panel and algorithm for mitochondrial haplogroup classification. The algorithm, Hi-MC, is implemented in R and makes use of PED/MAP file format for data input. We evaluated the performance of Hi-MC and demonstrate that classifications are comparable to the widely-used tool Haplogrep2. Hi-MC offers an algorithm that leverages a validated mtDNA SNP panel for mitochondrial haplogroup classification and is particularly valuable for studies in which sequencing is not feasible.10.7717/peerj.5149/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.5149/supp-2Supplemental Information 2Select haplogroup misclassifications are mapped to the simplified mitochondrial phylogenetic tree from Mitchell et al 2014 (PMID:24488180) for CEU , YRI Fi, and CHBClick here for additional data file.10.7717/peerj.5149/supp-3Supplemental Information 3Select haplogroup misclassifications are mapped to the simplified mitochondrial phylogenetic tree from Mitchell et al 2014 (PMID:24488180) for CEU , YRI Fi, and CHBClick here for additional data file.10.7717/peerj.5149/supp-4Supplemental Information 4Select haplogroup misclassifications are mapped to the simplified mitochondrial phylogenetic tree from Mitchell et al 2014 (PMID:24488180) for CEU , YRI Fi, and CHBClick here for additional data file.


Over consumption of fructose may lead to obesity and dyslipidemia and cause fructosylation-induced alterations in the structure and function of proteins. The aim of this study was to investigate the role of fructosylated-HSA-AGE in the pathogenesis of fatty liver (NAFLD and NASH) by biochemical, immunological and histological studies. Immunogenicity of fructosylated-HSA-AGE was probed by inducing antibodies in rabbits. Fructosylated-HSA-AGE was found to be highly immunogenic. Furthermore, fructosylated-HSA-AGE caused mild fibrosis with steatosis and portal inflammation of hepatocytes in experimental animals. Liver function test and dyslipidemic parameters in immunized animals were also found to be raised. Ultrasonography, which should form part of the assessment of chronically raised transaminases, shows fatty infiltration. Interestingly, alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, total cholesterol (TC) and triglyceride (TG) profiles confirms USG images of overweight, obese patients. Thus, present study demonstrates that fructosylated-HSA-AGE is hepatotoxic, immunologically active and may cause dyslipidemia. Fructose is a reducing and exceptionally lipogenic monosaccharide and invigorates triglyceride synthesis. Its utilization has been connected to obesity, insulin resistance, dyslipidemia, weakened glucose resistance and hypertension . The hepε-carboxymethyllysine (CML) in the liver, which is related with hepatic steatosis and hepatic aggravation in liver of obese people [Human serum albumin (HSA) is an extracellular heart-shaped three-domain protein that is mainly synthesized by hepatocytes and is the most abundant protein in plasma . Passagee people ,28. As oe people . Furthere people ,20.Our laboratory has also reported formation of fructosylated-HSA-AGEs .In this All experiments on animals were performed according to the instructions of the Council of International Organizations of Medical Sciences for the care and use of laboratory animals. The animal immunization protocols, experimental designs and studies were specifically approved by the Institutional Animal Ethics Committee (IAEC), J.N. Medical College, Aligarh Muslim University, Aligarh vide letter no. 401/GO/Re/S/2001/CPCSEA. The IAEC clearance was approved by the institutional Ethics Committee (IEC) vide letter no. 363/FM. The USG images of liver of healthy human subjects and overweight and obese patients were recorded according to the protocol described in the Helsinki declaration. Five milliliters of fresh blood samples were obtained from healthy volunteers after obtaining their verbal consent. Blood samples from patients were withdrawn after their verbal consent in presence of radiologist.3), dialysis tubing, anti-rabbit and anti-human IgG-alkaline phosphatase conjugates, p-nitrophenyl phosphate (pNPP), Protein A-agarose column, Tween-20 and Freund’s complete & incomplete adjuvants were purchased from Sigma Aldrich, USA. D-Fructose and silver nitrate were obtained from Qualigens, India. Polystyrene flat bottom microtiterELISA plates were from Nunc . All other chemicals used in the study used were of highest analytical grade.Human serum albumin (HSA), sodium dodecyl sulphate (SDS), sodium azide (NaN2). If BMI is 18.5 to <25, the individual is healthy, if BMI is 25.0 to <30, the individual is overweight and if the BMI is 30.0 or more, the individual is obese. The data on subjects included in this study have been summarized in The BMI of obese and overweight patients suspected of fatty liver was recorded and their blood samples were processed for ALT, AST, bilirubin, TC and TG levels. The BMI is an index of weight-for-height and is used to categorize overweight and obesity in adults. It is defined as person's weight in kilograms divided by the square of his height in meters  female rabbits weighing 1–1.5 kg(8–12 weeks) were placed in cages with square mesh with 12 h light and dark cycle. The room temperature was maintained at 28±2 °C and 50% humidity. All animals were given standard diet and water ad libitum.Rabbits were immunized with native HSA and fructosylated-HSA-AGE as described previously . BrieflyTM kits using LablifeChemMaster RT–1904C analyzer.ALT, AST, bilirubin were measured in sera by standard methods. Total cholesterol (TC) and triglycerides (TG) were estimated by BeneSpheratest− Acontrol).Direct binding ELISA was performed  to deterImmunoglobulin G (IgG) was isolated from preimmune and immune rabbits’seraas well from the sera of obese and overweight patients on protein A-Agarose column . The homAntigen-binding specificity of the antibodies was determined by inhibition ELISA. The plaAntigen-antibody interaction was confirmed by visual detection of immune complex formation . A constThe anatomical changes in the liver sections of immunized rabbits were studied after staining with hematoxylin and eosin . Slices 2. Each tissue block was divided into two equal halves and each half was attached to the newly exposed surface facing upwards. Spotter coater was used to gold coat the stubs. A scanning electron microscope (JEOL JSM-6510LV) with an acceleration voltage of 5 kV was used for capturing SEM images.Sample blocks for SEM were processed as described . Blocks Data are expressed as mean ± standard deviation (±SD). Statistical significance of the results was evaluated by Student’s t-test using GraphPad Prism7 Software. A p-value of <0.05 was considered as significant.Our previous study  on fructNative HSA and fructosylated-HSA-AGE were injected into rabbits andtitre of the induced antibodies was determined by direct binding ELISA. Anti-fructosylated-HSA-AGE antibodies showed antibody titre>1:6400  as compaSpecificity of the induced antibodies against respective immunogens was determined by inhibition ELISA. A maximum of 77.6% inhibition in anti-fructosylated-HSA-AGE antibodies binding was observed when fructosylated-HSA-AGE was used as inhibitor ; 50% inhIgG was isolated from pre-immune and immune rabbit sera by affinity chromatography on protein A-agarose column. Specificity of IgG purified from antiserum of fructosylated-HSA-AGE was evaluated by inhibition ELISA. A maximum of 82.7% inhibition in anti- fructosylated-HSA-AGE IgG binding was observed when fructosylated-HSA-AGE was used as inhibitor ;50%inhibThe data shown in For the visual detection of the immunogen-antibody interaction, gel retardation assay was performed in polyacrylamide gel containing SDS. The pattern of bands in Weekly injections of 250 μg of fructosylated-HSA-AGE for 7 weeks caused slight changes in ALT, AST, bilirubin, TC and TG level . We deciLiver section of rabbit with native HSA showed normal morphology . HoweverIt is widely held that persistent hepatic inflammation can trigger the activation of stellate cells and production of collagen in excess, which may deposit around the portal and central vein area. Liver section of rabbit immunized with fructosylated-HSA-AGE showed collagen fibers around hepatocytes in  as compaThe study comprised 10 sera each of healthy subjects, obese patients and overweight patients. Their AGE, BMI, ALT, AST, AST/ALT, TC and TG values are given in Direct binding ELISA was carried out to determine the level of autoantibodies against fructosylated-HSA-AGE in sera of healthy subjects, overweight patients and obese patients and the results are shown in The specificity of autoantibodies against fructosylated-HSA-AGE in some selected sera (which showed highest binding in direct binding ELISA) of obese and overweight patients was tested by inhibition ELISA. Data presented in The consolidated effects of increased food consumption, low energy consumption, high blood sugar, high cholesterol and increased reactive oxidative stress can increase the formation of reactive intermediates and AGEs in obesity. The current dietary movement of fructose is likely to affect in vivo fructose concentrations and their metabolites in tissues and blood . A couplFructosylated-HSA-AGE was found to be a potent immunogen when injected into rabbits and induce high-titer antibodies as compared to native HSA. It indicates that fructose induced modifications on HSA have contributed to its immunogenicity, probably due to generation of neo-epitopes. It may be recalled that lysine enhances the immunogenicity of HSA . Many stFructose modification of HSA resulted in fructosylated-HSA-AGEs. These AGEs were deleterious and toxic. A few investigations have made it sufficiently evident that AGEs are engaged in the generation of oxidative stress, which intensify liver damage through liver inflammation, HSCs activation and amalgamation of extracellular matrix (ECM), causing liver fibrosis ,49,50. HA report suggests that with AST/ALT < 1, the liver diseases are often correlated to obesity and high cholesterol . UltrasoThe strong binding of autoantibodies from obese and overweight patients to fructosylated-HSA-AGE points towards the involvement of modified lysine residues of albumin in the fatty liver disease. Autoantibodies detected in obese and overweight patients may be due to the generation of neo-epitopes on the HSA because of fructosylation.Fructose ingestion increases genes encoding lipogenic enzymes via activation of SCAP/SREBP pathway in the liver in a controlled manner. Excessive amount of fructose consumption leads to generation of AGEs, which results in a change, evoking delayed initiation of SCAP protein by restraining its degradation . SubsequFrom our data it may be concluded that fructose overconsumption may contribute in the development of obesity and dyslipidemia. Furthermore, it can rapidly form advanced glycation end products, which are hepatopathic as well as immunogenic.


Corynebacterium ulcerans, one of three species of Corynebacterium (in addition to C. diphtheriae and C. psuedotuberculosis) that can harbor the diphtheria toxin–producing gene was initially identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry performed on an isolate obtained from culture of the pseudomembrane at a Missouri hospital on December 13. The Missouri Department of Health and Senior Services (MDHSS) laboratory-confirmed C. ulcerans by culture and forwarded the isolate to CDC for toxin testing. On December 28, CDC confirmed toxin-producing C. ulcerans. The patient had no systemic symptoms, was not hospitalized, and did not receive diphtheria antitoxin. On January 11, 2019, following multiple membrane removals and no residual membrane; cultures of conjunctival swabs tested by the hospital were negative for C. ulcerans. The patient was not up-to-date for tetanus-diphtheria (Td) vaccine and had postponed vaccination because of his ongoing cancer treatment.On December 12, 2018, an immunocompromised man with non-Hodgkin’s lymphoma, aged 73 years, was evaluated by an ophthalmologist for left eyelid redness, swelling, and eye discharge and received a diagnosis of ligneous (pseudomembranous) conjunctivitis. The pseudomembrane was debrided and sent for culture, and the patient was prescribed oral amoxicillin clavulanate and moxifloxacin eye drops, with topical loteprednol and cyclosporine to decrease the robust inflammatory response. C. ulcerans. The household contact was not offered antibiotic postexposure prophylaxis (PEP) and declined a Td booster. Ophthalmology staff members who had direct contact with the patient reported wearing recommended personal protective equipment and declined PEP. No identified contacts developed disease. The patient lived with two dogs; neither was reported to be ill or examined by a veterinarian, and the patient declined to have the dogs tested for C. ulcerans.Case investigation by MDHSS and the St. Louis County Department of Public Health identified one household contact. Paired nasal and throat swabs collected from the patient (posttreatment) and the household contact to assess carriage were negative by culture for Corynebacterium diphtheriae are transmitted person-to-person and cause respiratory and cutaneous diphtheria; infections of other mucous membranes, such as the eye, have been reported  should be assessed, and contacts who are not up-to-date should be offered vaccination (C. ulcerans should follow treatment guidelines for patients infected with C. diphtheriae (C. diphtheriae or C. ulcerans (C. ulcerans infection can be acquired from pets, particularly by elderly or immunocompromised persons (C. diphtheriae and C. ulcerans can become toxigenic through lysogeny by beta-corynebacteriophages harboring the diphtheria toxin gene. Circulation of toxigenic C. ulcerans in animals highlights an animal reservoir for corynebacteriophages. This poses programmatic challenges to eradicating diphtheria caused by toxigenic C. diphtheriae and emphasizes the need to maintain high human population immunity through diphtheria vaccination, including recommended decennial booster doses (Antibiotic treatment of illnesses caused by toxin-producing