Mini Clinical Evaluation Exercise (Mini-CEX) and Direct Observation of Procedural Skills (DOPS) are used as formative assessments worldwide. Since an up-to-date comprehensive synthesis of the educational impact of Mini-CEX and DOPS is lacking, we performed a systematic review. Moreover, as the educational impact might be influenced by characteristics of the setting in which Mini-CEX and DOPS take place or their implementation status, we additionally investigated these potential influences.We searched Scopus, Web of Science, and Ovid, including All Ovid Journals, Embase, ERIC, Ovid MEDLINE(R), and PsycINFO, for original research articles investigating the educational impact of Mini-CEX and DOPS on undergraduate and postgraduate trainees from all health professions, published in English or German from 1995 to 2016. Educational impact was operationalized and classified using Barr’s adaptation of Kirkpatrick’s four-level model. Where applicable, outcomes were pooled in meta-analyses, separately for Mini-CEX and DOPS. To examine potential influences, we used Fisher’s exact test for count data.standardized mean difference (SMD) = 0.26, p = 0.014; DOPS: SMD = 3.33, p<0.001). No studies were found on higher Kirkpatrick levels. Regarding potential influences, we found two implementation characteristics, “quality” and “participant responsiveness”, to be associated with the educational impact.We identified 26 articles demonstrating heterogeneous effects of Mini-CEX and DOPS on learners’ reactions (Kirkpatrick Level 1) and positive effects of Mini-CEX and DOPS on trainees’ performance (Kirkpatrick Level 2b; Mini-CEX: Despite the limited evidence, the meta-analyses demonstrated positive effects of Mini-CEX and DOPS on trainee performance. Additionally, we revealed implementation characteristics to be associated with the educational impact. Hence, we assume that considering implementation characteristics could increase the educational impact of Mini-CEX and DOPS. Since the introduction of the Mini Clinical Evaluation Exercise (Mini-CEX) in 1995 and the Direct Observation of Procedural Skills (DOPS) in 2003, their use has spread rapidly around the world , which cBesides medical training, Mini-CEX and DOPS have also been introduced in other health professions, such as nursing, midwifery or dentistry –9. The oDue to their feedback components, Mini-CEX and DOPS are increasingly used as methods of formative assessment, with the goal of shaping and supporting trainees’ learning , 12. DatMini-CEX and DOPS should be used in the workplace during daily clinical work. However, it has been shown that the assessments are perceived as additional workload . Hence, Thus, we aim to answer the following research questions:“What evidence is there that Mini-CEX and DOPS have an educational impact on undergraduate and postgraduate trainees in the health professions?”“Are characteristics of the setting in which Mini-CEX and DOPS take place, or the implementation status of Mini-CEX/DOPS associated with the educational impact of the tools?”Demonstrating the educational impact of Mini-CEX and DOPS in a systematic review would be helpful for educators in terms of justifying the use of the tools in health professions training. Knowing which characteristics of the setting and of the implementation status influence the educational impact of Mini-CEX and DOPS would advance our understanding of when and how to use Mini-CEX and DOPS in order to increase their educational benefits.To guide our work, we used the recommendations of Cook and West  and follhttp://dx.doi.org/10.17504/protocols.io.nmpdc5n) and data (https://doi.org/10.6084/m9.figshare.6275288.v1) are available online.The authors did not receive any specific funding for this review. A PRISMA checklist was completed and adhered to . To answer our second research question, we extracted the relevant data from the studies included and analyzed whether there are associations of the educational impact with characteristics of the setting and with characteristics of the implementation status. The study protocol , and Ovid, including All Ovid Journals, Embase, ERIC, Ovid MEDLINE(R), and PsycINFO (step IV). Search terms were "mini-CEX" OR "mini clinical evaluation exercise" OR "direct observation of procedural skills" OR "work-based assessment" OR "workplace-based assessment" OR “supervised learning event” OR “supervised learning events”. We analyzed all articles published between the first description of Mini-CEX in 1995/DOPS in 2003 and December 2016 (date of access: 02.12.2016). Hits from the different databases were exported to an EndNote library and duplicates were removed.To identify articles relevant to our research question, we defined the following selection criteria (step V):Article type: Original research articles were included; other article types such as reviews, conference abstracts, letters or editorials were excluded.Language: Articles in English and German were included; articles in other languages were excluded.Population: Undergraduate and postgraduate trainees from all health professions were included.Object of investigation/intervention: Articles investigating Mini-CEX or DOPS provided by experts in real-life clinical encounters were included; other interventions such as Multisource Feedback, case based discussions or Mini-CEX and DOPS used in simulation settings were excluded.Outcome: Articles describing the educational impact of Mini-CEX or DOPS, which was operationalized using Barr’s adaptation of Kirkpatrick’s four-level model , were inTwo authors independently scanned the articles for eligibility. Differences in article selection were discussed until consensus was reached. Articles were selected in two rounds: First, titles and abstracts were scanned, and second, remaining articles were selected based on full texts. In the first round, 63 out of 1478 articles were not in consensus and had to be discussed based on the full text. Based on the full text, inclusion/exclusion was clear and all articles were classified unanimously. To visualize the review process, we used the four-phase flow diagram as recommended in the PRISMA statement .From the articles included in our review, the authors extracted the following key information (step VI): setting , study design , implementation status  , and repAs a final step, the authors analyzed the data regarding the quality of the studies, educational impact, and the potential influences on the educational impact (step VII). Effects of Mini-CEX and DOPS were analyzed separately. Articles describing the educational impact of both Mini-CEX and DOPS were separated into individual studies.The methodological quality of the studies was assessed using the MERSQI  . The MERReported outcomes were classified according to Barr’s adaptation of Kirkpatrick’s four-level model . The modI2- and tau2- statistics [For meta-analysis, effect sizes were calculated using Hedges’ g (standardized mean differences) for each comparison . If infoatistics . A randoAs potential influences on the educational impact of Mini-CEX/DOPS, we considered characteristics of the setting and of the implementation status . Within α < 0.05.To analyze whether there is an association of the educational impact with characteristics of the setting and with characteristics of the implementation status of Mini-CEX/DOPS, we used Fisher’s exact test for count data . For staWe assume a negligible risk of bias across and within studies. One major bias across studies is the publication bias favoring the publication of studies demonstrating positive results. With regard to Mini-CEX and DOPS, however, a relevant proportion of studies show negative results –29. We tOur search identified 2397 records. After duplicates were removed, 1478 records remained. By screening titles and abstracts, 1367 records were removed. The remaining 111 records were assessed based on their full text. Of these, 85 articles were excluded, and 26 articles met all eligibility criteria and were included in our review .Seventeen articles were on Mini-CEX , 30–42, Eighteen articles investigated the effect of Mini-CEX on Kirkpatrick level 1 , 47, 48.Seven studies reported effects of DOPS on Kirkpatrick level 1 , 45–48. Two studies reported high educational impact , three studies reported medium educational impact , and two studies reported low educational impact (DOPS was not perceived as useful). For detailed information on the studies, please refer to We found no studies reporting an educational impact of Mini-CEX or DOPS on Kirkpatrick level 2a.Two articles, encompassing three studies, reported effects of Mini-CEX on Kirkpatrick level 2b , 38. Thestandardized mean difference (SMD) of 0.26  .Educational impact was high in two studies and medium in one study. Effect sizes ranged from 0.10 to 0.48 and were pooled in a meta-analysis, which revealed a significant = 0.014) . Effect Two articles reported on the educational impact of DOPS on Kirkpatrick level 2b , 44. TheSMD of 3.33  .Educational impact was high in both studies. As both studies reported two outcome measurements each, two effect sizes were calculated for each study. Effect sizes ranged from 2.53 to 6.02. Pooling effect sizes in a meta-analysis revealed an p<0.001) . Effect We found no studies reporting effects of Mini-CEX or DOPS on Kirkpatrick levels 3 or 4.n = 9, p = 0.004) and participant responsiveness  , its mandatory use , the assessment sheet , fidelity , dosage I , dosage II , program differentiation , monitoring of control , program reach , and adaptation .Our analysis revealed that the educational impact of Mini-CEX was positively associated with two characteristics of the implementation status: quality of Mini-CEX  Tables  and 3. Nn = 6, p = 1), participant responsiveness , or program differentiation . With regard to the purpose of DOPS, the assessment sheet, fidelity, dosage I and II, quality, monitoring of control, program reach, and adaptation, the reported data were insufficient to calculate Fisher’s exact test for count data.Analyzing the studies that investigated DOPS, no significant links between the setting or the implementation status and the educational impact were found. There was no significant link between the educational impact and the mandatory use of DOPS , showing mixed results. Four articles reported effects on trainee performance (Kirkpatrick level 2b) and were synthesized into two meta-analyses: one on DOPS and one on Mini-CEX. Both meta-analyses revealed a positive effect of Mini-CEX or DOPS on trainee performance. We found two characteristics of implementation status to be associated with the educational impact: quality and participants’ responsiveness.In the meta-analyses the effect of DOPS was about ten times higher than that of Mini-CEX , 38, 44.Since the educational impact in the meta-analysis on DOPS as well as the reported outcomes on Kirkpatrick level 1 on Mini-CEX and DOPS varied, we examined whether the setting in which the tools take place and their implementation status affect their educational impact. In fact, we found two associations between the implementation status of Mini-CEX and its educational impact: quality and participant responsiveness. The correlation between the quality of implementation and the educational impact indicates that low quality is associated with low educational impact and high quality is associated with high educational impact. In other words, the proper conducting of Mini-CEX, including a realistic reflection of trainee performance during direct observation, followed by a constructive feedback conversation, seems to be a prerequisite for its educational impact –51. ThisAs hypothesized, our study demonstrates that proper implementation is positively associated with the educational impact of Mini-CEX. This finding has several implications for practitioners and researchers in health professions education. For practitioners, our results suggest that it is essential to assure proper implementation and integration of the assessments into daily routine in order for them to have an educational impact. For researchers, it is crucial to take implementation characteristics into account when evaluating the educational impact of Mini-CEX and DOPS. For example, a negative result, such as no effect of Mini-CEX/DOPS on trainees’ performance, might be explained by improper implementation of the tools. Addressing implementation characteristics, such as fidelity, dosage, quality, participant responsiveness, program differentiation, monitoring of control, program reach, and adaptation, when evaluating the tools can also help in improving the educational impact in the future. To facilitate further research on factors influencing the educational impact, rigorous reporting is necessary. Above and beyond the usual reporting standards , 54, theTo our knowledge, we are the first to report meta-analyses on the educational impact of Mini-CEX and DOPS. By applying a sensitive and broad search strategy, including undergraduate and postgraduate medical trainees as well as trainees from health professions other than human medicine, we assume that we detected all relevant articles on the educational impact of Mini-CEX and DOPS. To analyze potential influences on the educational impact of Mini-CEX and DOPS, we applied a framework of implementation characteristics according to Durlak and DuPre .Despite our comprehensive search strategy, we found only four articles which reported effects of Mini-CEX/DOPS on Kirkpatrick level 2. Whether the positive effects on undergraduate trainees also hold true in postgraduate settings needs to be investigated. Although we analyzed eleven potential influences on the educational impact of Mini-CEX and DOPS, we found only two to be significantly associated with the educational impact of Mini-CEX. Due to the limited data basis, we might have underestimated the number of associations of the educational impact of Mini-CEX and DOPS with characteristics of the setting and of the implementation status.Despite the limited evidence regarding the educational impact of Mini-CEX and DOPS as well as the limited reports on implementation status, we demonstrated positive effects of Mini-CEX and DOPS on trainee performance in meta-analyses and identified two implementation characteristics to be associated with the educational impact of Mini-CEX. The positive results of the meta-analyses might help educators to justify and strengthen the use of these tools in health professions training. The finding that two characteristics of the implementation status are associated with the educational impact puts further emphasis on the proper implementation of Mini-CEX and DOPS in order to increase their educational impact.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 TableClassification of extracted data is displayed in italics. Abbreviations: ACE , CbD (case based discussion), CP (case conference), FY (foundation year), ITER , JCP , Mini-ACE , Mini-PAT (mini-peer assessment tool), MSF (multisource feedback), OSCE , OSLER (objective structured long examination record), PDA , PSQ (patient satisfaction questionnaire), WPBA (workplace-based assessment).(PDF)Click here for additional data file.


Alzheimer’s disease (AD) is complex, with genetic, epigenetic, and environmental factors contributing to disease susceptibility and progression. While significant progress has been made in understanding genetic, molecular, behavioral, and neurological aspects of AD, relatively little is known about which environmental factors are important in AD etiology and how they interact with genetic factors in the development of AD. Here, we propose a data-driven, hypotheses-free computational approach to characterize which and how human gut microbial metabolites, an important modifiable environmental factor, may contribute to various aspects of AD.We integrated vast amounts of complex and heterogeneous biomedical data, including disease genetics, chemical genetics, human microbial metabolites, protein-protein interactions, and genetic pathways. We developed a novel network-based approach to model the genetic interactions between all human microbial metabolites and genetic diseases. We identified metabolites that share significant genetic commonality with AD in humans. We developed signal prioritization algorithms to identify the co-regulated genetic pathways underlying the identified AD-metabolite (brain-gut) connections.We validated our algorithms using known microbial metabolite-AD associations, namely AD-3,4-dihydroxybenzeneacetic acid, AD-mannitol, and AD-succinic acid. Our study provides supporting evidence that human gut microbial metabolites may be an important mechanistic link between environmental exposure and various aspects of AD. We identified metabolites that are significantly associated with various aspects in AD, including AD susceptibility, cognitive decline, biomarkers, age of onset, and the onset of AD. We identified common genetic pathways underlying AD biomarkers and its top one ranked metabolite trimethylamine N-oxide (TMAO), a gut microbial metabolite of dietary meat and fat. These coregulated pathways between TMAO-AD may provide insights into the mechanisms of how dietary meat and fat contribute to AD.Employing an integrated computational approach, we provide intriguing and supporting evidence for a role of microbial metabolites, an important modifiable environmental factor, in AD etiology. Our study provides the foundations for subsequent hypothesis-driven biological and clinical studies of brain-gut-environment interactions in AD. Our resSeveral secondary bile acids ranked highly, including chenodeoxycholic acid glycine conjugate (top 4), taurochenodesoxycholic acid (top 24), and taurodeoxycholic acid (top 26). Secondary bile acids are potent inhibitors of apoptosis in different cell types. The potential role of apoptosis in Alzheimer’s disease (AD) has been an area of intense research in recent years. Studies provide evidence for the anti-apoptotic role of bile acids in experimental AD .Both cadaverine and putrescine ranked highly. Cadaverine and putrescine are polyamine, which are known to be closely related with cell growth, cell proliferation, and synthesis of proteins and nucleic acids. The neurotoxic amyloid ?-peptide in AD is known to up-regulate polyamine metabolism by increasing ornithine decarboxylase activity and polyamine uptake by initiating free radical damage. Polyamines play an important role in response to neurodegenerative conditions. Altered levels of polyamines have been found in tissue, hair and body fluids of patients with neuromuscular diseases and neurodegenerative conditions .Trans-ferulic acid ranked at top 14. Trans-ferulic acid is one of the most abundant phenolic acids in fruit and vegetables and a potent antioxidant. Free-radicals derived from mitochondrial dysfunction and from the cyclooxygenase enzyme activity play a role in oxidative damage of brain. Food rich in ferulic acid and other the antioxidant is considered a nutritional approach to reduce oxidative damage and amyloid pathology in AD –31.κB (NF- κB) inhibitor, antioxidant and antiinflammatory agent. PDTC activates Akt and improves spatial learning in mouse model of AD [Pyrrolidine ranked at top 12. Pyrrolidine dithiocarbamate (PDTC) is a nuclear factor- el of AD .Recent epidemiological, clinical, and experimental data suggest that cholesterol may play a role in AD pathogenesis and plaque formation. Cholesterolemia is involved in the development of amyloid in AD. Recent work demonstrated that diet-induced hypercholesterolemia resulted in dramatic acceleration of the neuropathological and biochemical changes in the transgenic mice , 34.D-glutamic acid ranked at top 17. Glutamate is the major fast excitatory neurotransmitter and is involved in almost all CNS functions. Severe disturbances in glutamate neurotransmission has been linked with the pathophysiological processes underlying AD .TMAO ranked at top one for AD biomarkers. Recent studies have shown a mechanistic link between TMAO, a gut microbial metabolite of dietary meat and fat, and risk of CVDs, and established an obligatory role of gut microbiota in the generation of proatherosclerotic TMAO from dietary L-carnitine and phosphatidylcholine, abundantly present in red meat and dietary fat, respectively –39. Our We investigated the potential genetic pathways underlying the strong association between TMAO and AD. We identified a total of 27 genetic pathways associated with AD biomarkers, and a total of 171 pathways associated with TMAO-related genes. Among these pathways, 9 pathways are involved in both AD and TMAO, including pathways related to “Alzheimer’s disease,” “Axon guidance,” “immune systems,” “neuron signaling,” and “lipid and protein metabolism”. Table Alzheimer’s disease is complex, with genetic, epigenetic, and environmental factors contributing to disease susceptibility and progression. Accumulating clinical and biomedical evidence indicates that gut microbiota and their metabolites influence brain function and behavior in a range of central nervous system (CNS) disorders. Employing an integrated computational approach, we provide intriguing and supporting evidence for a role of microbial7metabolites in AD etiology. Our algorithm is highly dynamic and flexible and additional disease genetic data can be easily incorporated. Our study could serve as a starting point for others to conduct hypothesis-driven functional studies of gut-brain-environment interactions in AD and other diseases. In summary, the identification of microbial metabolites and the understanding of their role as key mediators through which these bacteria promote/protect against AD may provide insight into the basic mechanisms of AD etiology, facilitate our understanding of the complex host genome-microbiome interactions in AD pathogenesis, and enable/activate new possibilities for AD diagnosis, prevention, and treatment.


Microbiologists traditionally study population rather than individual cells, as it is generally assumed that the status of individual cells will be similar to that observed in the population. However, the recent studies have shown that the individual behavior of each single cell could be quite different from that of the whole population, suggesting the importance of extending traditional microbiology studies to single-cell level. With recent technological advances, such as flow cytometry, next-generation sequencing (NGS), and microspectroscopy, single-cell microbiology has greatly enhanced the understanding of individuality and heterogeneity of microbes in many biological systems. Notably, the application of multiple ‘omics’ in single-cell analysis has shed light on how individual cells perceive, respond, and adapt to the environment, how heterogeneity arises under external stress and finally determines the fate of the whole population, and how microbes survive under natural conditions. As single-cell analysis involves no axenic cultivation of target microorganism, it has also been demonstrated as a valuable tool for dissecting the microbial ‘dark matter.’ In this review, current state-of-the-art tools and methods for genomic and transcriptomic analysis of microbes at single-cell level were critically summarized, including single-cell isolation methods and experimental strategies of single-cell analysis with NGS. In addition, perspectives on the future trends of technology development in the field of single-cell analysis was also presented. Microbiologists usually study microorganisms by deciphering their physiology, internal interactions, and even genetic information. Traditionally, these studies are all carried out at the population level, typically using millions to billions of cells for analysis in bulk, and assuming the status of individual cells is similar to that observed in the population. Although these results are, no doubt, informative, they often neglect any heterogeneity that is possibly present in the population. Meanwhile, the recent studies have shown that cell-to-cell heterogeneity at both cellular and molecular levels in isogenic population could be an order of magnitude greater than previously thought , suggestHeterogeneities could result from either phenotypic difference between isogenic cells or genetic diversity at population level . Mechaniin situ interactions among organisms . The major challenge of this step is: how to isolate cells of interest accurately in a high-throughput manner and without causing any genetic or physiological change to the target cells. Basically, methods being applied for microbial single-cell isolation could be classified as two principal approaches: micromanipulation and random encapsulation  PCR (LA-PCR)  and IRS-TthPrimPol, which has a wide range of template specificity, serves as primase for φ29 polymerase mediated MDA. During the reaction, TthPrimPol binds to the denatured DNA and synthesizes short DNA primers. The DNA primers are recognized and extended by φ29 polymerase. Then, TthPrimPol catalyzes new rounds of priming on the elongated single-strand DNA, followed by further rounds of strand-displacement synthesis and resulting in exponential amplification   and MALBR2 = 0.53) was nearly the same as GenomePlex (R2 = 0.56), while MDA gave a very poor correlation (R2 = 0.02)  . The Tru = 0.02) . In addi = 0.02) . This su = 0.02) . As new  = 0.02) . As micrBesides amplification methods, previous reports also found that by using microfluidic devices, microbial single-cell analysis could obtain a better performance comparing with the traditional tube-based approach . With hiPrior to whole-genome transcriptomic analysis, relative quantification methodologies have been developed to measure expression of small number of genes at single-cell level. For example, methods using fluorescent reporter proteins coupling with high-throughput data acquisition approaches such as flow cytometry have been widely applied for detecting gene expression heterogeneities within the microbial population . In addide novo NGS approach. Compared to genomic analysis, transcriptomic analysis for microbes at single-cell level is much more challenging for several reasons. First, microbial cells usually contain picogram to femtogram level RNA molecules . For example, full-length RNA-seq methods such as Smart-seq/Smart-Seq2, and Quartz-seq could sequence the transcripts in their entirety, and thus are suggested for de novo sequencing and the detection of SNPs and mutations. However, these methods are not compatible with strand-specific protocol and UMI. Methods such as STRT-seq, CEL-seq/CEL-seq2, MARS-seq, and Drop-seq are all compatible with strand-specific protocol and UMI, although they tend to be 5′ or 3′ end biased. While UMI approach in single-cell sequencing could reduce amplification noise and provide more accurate expression quantification, strand-specific sequencing could provide more information for antisense transcript discovery, genome annotation, and expression profiling. In conclusion, current single-cell RNA-seq methods are still facing a trade-off between coverage and uniformity , SMRT sequencing (PacBio), and nanopore sequencing (Oxford Nanopore) could sequence DNA/RNA molecules at single-molecule level and prove to be possible to sequence DNA/RNA molecules directly from bulk-cells without pre-amplification . AlthougAs a rapidly growing field, single-cell analysis plays a significant role in extending our understanding of microorganisms by revealing how individual cells perceive, respond and adapt to the environment, and determine the fate of the whole population. The key drivers of new technology for single-cell analysis will be advancement in throughput, integration of isolation and amplification, and integrated analysis with multiple ‘omics.’ Even with many challenges still ahead, we believe that this field will receive a tremendous boost with progress of several related fields, such as microfluidic devices and new sequencing platforms.WZ envisioned this project. ZC, LC, and WZ wrote the manuscript. All authors have read and agreed on the manuscript.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.


Glioma has been considered to be the most frequent primary tumor within the central nervous system (CNS). The complexity of glioma, especially the existence of the blood-brain barrier (BBB), makes the survival and prognosis of glioma remain poor even after a standard treatment based on surgery, radiotherapy, and chemotherapy. This provides a rationale for the development of some novel therapeutic strategies. Among them, receptor-mediated drug delivery is a specific pattern taking advantage of differential expression of receptors between tumors and normal tissues. The strategy can actively transport drugs, such as small molecular drugs, gene medicines, and therapeutic proteins to glioma while minimizing adverse reactions. This review will summarize recent progress on receptor-mediated drug delivery systems targeting to glioma, and conclude the challenges and prospects of receptor-mediated glioma-targeted therapy for future applications. Glioma, which arises from glial cells, is by far the most frequent and lethal brain tumor, accounting for approximately 80% of malignant tumors in the central nervous systems (CNS) ,2. AccorThe BBB is made up of brain capillary endothelial cells (BCECs) which are joined together by tight junctions. It plays an important role as a selective barrier and a critical regulator of brain homeostasis, separating the brain from circulating toxins and potentially harmful chemicals, and allowing access of a small subset of molecules with the appropriate size (400–600 Da), charge, and lipid solubility ,10,11,12In recent years, plenty of strategies have been developed for overcoming the BBB and/or targeting to glioma such as receptor-, transporter-, or adsorption-mediated drug delivery according to different transport mechanisms ,16. As oThe single ligand-modified drug delivery systems are conjugated with just one ligand that could target to both BBB and glioma, or glioma alone, which could realize cascade-targeting or glioma-targeting functions, respectively. The detailed illustration of the single ligand-modified targeting systems are shown in Some receptors have been reported to be highly expressed on both BBB and glioma, which provide the cascade-targeting sites for receptor-mediated drug delivery systems. The single targeting ligand that could mediate both transportation of drugs across the BBB and their internalization into glioma cells is referred figuratively as a “multistage rocket”, which represents the simplest approach for secondary targeted delivery.in vivo to some extent [As an essential element of the human body, cellular iron plays a crucial role in cell proliferation ,40. The e extent . Lots ofd,l-lactic-co-glycolic acid) (PLGA) NPs loading DOX and paclitaxel (PTX) (DOX-PTX-NPs-Tf) to bypass the BBB and subsequently target to the glioma [in vivo anti-glioma studies demonstrated that DOX-PTX-NPs-Tf treatments resulted in a substantial reduction in tumor size compared to Tf-unconjugated NPs. More recently, the use of Tf in preparation of cascade-targeting anti-glioma drug delivery systems has risen sharply, which is related to the high affinity for TfR and the effective treatments in the past studies [Since TfR was found as a highlighted target for mediating drugs across the BBB, many targeting moieties aiming at TfR have been discovered. As an innate ligand, Tf is a naturally-existing protein possessing high affinity for TfR . Liu ande glioma . It is s studies ,44,46. Set al. [However, it has been reported that high concentration of endogenous Tf 2250 nM) may produce competitive inhibition to the Tf-modified drug delivery systems . Therefo50 nM mayet al. . They pret al. . Despiteet al. has drawn researchers’ attention recently [in vivo anti-tumor studies. As mentioned above, both the T7 and the hybrid peptide can be exploited as appropriate candidates for clinical application owing to their advantage of small steric hindrance, stability and good mediators for crossing the BBB.Recently, some peptides have been greatly impressed by considerable researchers due to their facile synthesis methods and high affinity for TfR. A seven peptide  has been reported to specifically bind to TfR ,51,52. Irecently ,26. The As a member of the Tf family, lactoferrin (Lf) is a single-chain cationic iron-binding glycoprotein . The higin vivo [Apart from their therapeutic benefits, these receptor-mediated systems can also play a crucial role in diagnosis of glioma. The group of Yang explored Lf-conjugated magnetic nanogels (Lf-MPNA) as a MRI contrast agent for glioma detection in vivo . The MR To sum up, Lf can be exploited as a targeting ligand conjugated to some nano-enabled carriers to yield an efficient glioma-targeting vector.et al. created a synthetic LDL particle using a lipid emulsion and a peptide composed of LDLR binding domain of ApoB [Low density lipoprotein receptor (LDLR), which is able to prompt the internalization of lipoprotein, has been reported to be highly expressed on the BBB and glioma cells ,65. More of ApoB . This LD of ApoB . After lin vitro. In the meantime, the NPs exhibited stronger brain permeation, glioma targeting, and enhanced chemotherapeutic effect compared to other groups in vivo. These results revealed the feasibility of peptide-22 as a cascade-targeting moiety for LDLR.Some targeting moieties such as ApoB, apolipoprotein E (ApoE), or some peptides corresponding to the LDLR-binding domain of ApoE or ApoB have been proven to be effective in LDLR-targeted therapy of neoplastic diseases ,72. Howein vitro BBB model and the ability to cross the BBB in vivo via the LRP-mediated pathway [et al. reported that the MTf-adriamycin conjugate significantly increased the survival of mice implanted with C6 glioma cells compared to injections of free adriamycin [Low density lipoprotein receptor-related protein (LRP) is a type of transmembrane proteins belonging to the LDL receptor family ,74. The  pathway ,80. In r pathway . The enh pathway . The con pathway . Althoug pathway . It is i pathway . Gabathuriamycin . In addiin vitro. In vivo experiments showed significant anti-glioma effect and improvement in the survival time of tumor-bearing mice when compared with other formulations, like non-targeting nanocarriers. Moreover, Chen et al. fabricated FA-conjugated N-(trimethoxysilylpropyl) ethylene diamine triacetic acid (TETT) modified MnO NPs (MnO-TETT-FA) as tumor-specific MRI contrast agents for glioma detection [Folate is a low-molecular-weight pterin-based vitamin. FR is essential to capture exogenous folate and various derivatives into the cell cytosol due to the lack of key enzymes of the folate biosynthetic pathway in animal cells . Studiesetection . MR imagetection ,86.et al. reported that PEGylated immunoliposomes (PILs) modified with 83–14 murine monoclonal antibody, an antibody to the human insulin receptor, could target the gene formulation to brain tumors in vivo [et al. utilized a non-toxic mutant of diphtheria toxin (known as CRM197) as the receptor-specific carrier protein which conjugated directly to horseradish peroxidase [Beyond the receptors listed above, there are still several receptors being referred as targeting sites for therapeutic agents highly expressed on the BCECs and glioma. One example is the insulin receptor, a membrane glycoprotein present in BCECs as well as glioma cells . Zhang e in vivo . Many st in vivo . Gaillarroxidase . ResultsUsually, with the aggravation of glioma, the proliferation and invasion of cancer cells will cause a local disruption of the BBB and produce various mediators which can increase the permeability of the capillary endothelium ,90. On tIt has been reported that some interleukin receptors (ILRs) are highly expressed in many tumorous cells because they can contribute to malignant progression and apoptosis resistance of various cancer types, including glioma . Among tAs one of the inflammatory cytokines, interleukin 13 (IL-13) can bind to two receptor chains, IL-13Rα1 and IL-13Rα2 ,93. IL-1et al. used a cyclic RGD peptide to conjugate the chain-like NPs (nanochain) [As known, integrin is a member of cell adhesion receptors’ family, playing an important role in tumor growth, invasion, and metastasis . It is cnochain) . After bTwo ligands in this kind of systems may play independent functions to different targeting sites, which then mediate drug delivery systems to overcome different barriers for final glioma targeting.et al. came up with a cascade-targeting strategy in order to achieve high and precise brain glioma targeting. They employed PEG-PCL NPs modified with two kinds of targeting ligands [The first strategy of the cascade-targeting systems is to modify the nanocarriers with two kinds of ligands. One of the ligand targets across the BBB, and the other ligand targets tumor cells. Gao  ligands . The cel ligands .et al. [in vitro BBB model compared to that of G4-DOX-PEG-Tf (4.93%) and G4-DOX-PEG (4.62%). He and coworkers developed another dual ligand-mediated cascade-targeting DOX-loaded NPs conjugated with Tf and wheat germ agglutinin (WGA), which has the potential to transfer drugs across the BBB and further target glioma cells [in vitro BBB model and glioma in in vivo experiments showed that this bifunctional polymersome could enhance BBB transport and tumor accumulation. In addition, a mass of dual cascade-targeting drug delivery systems including daunorubicin-loaded liposome conjugated with p-aminophenyl-α-d-manno-pyranoside (MAN) and Tf, liposome co-modified with T7 and TAT, have been proved to possess stronger BBB-crossing and glioma-accumulating capability compared with single ligand-modified systems [Additionally, the second strategy of the cascade-targeting systems is to build nanocarriers modified with two kinds of ligands, with one targeting to the BBB and tumor cells, and the other promoting the targeting effect. The former ligands are usually some targeting moieties binding to their corresponding receptors, and the latter ligands may be some cell penetrating peptides or some targeting moieties binding to the corresponding receptors, transporters, and so on. Drug delivery system, G4-DOX-PEG-Tf-TAM, was synthesized with Tf and Tamoxifen (TAM) conjugatd to polyamidoamine (PAMAM) dendrimer by Li et al. . In thisma cells . The PAMma cells . As a 28 systems ,105. Somet al. utilized RGD and IP as ligands to modify polymeric NPs (IRNPs) [in vivo study revealed that the fluorescent intensity of DiR-loaded IRNPs in glioma was 3.82-fold that of unmodified NPs. These results demonstrated that the co-modification of RGD and IP could increase the glioma targeting effect, which proved the superiority of dual ligand-modified targeting delivery systems. Although lots of dual ligand-modified targeting systems showed more satisfactory targeting effects, the systems with a single ligand are also other choices which could simplify the preparation of therapeutics. Thus, different research may choose the best way in accordance with requirements in the further.Similar to single ligand-modified glioma-targeting systems, the dual ligand-conjugated systems can specifically target the receptors on the glioma and/or neovasculatures. Gao  (IRNPs) . The modFor glioma diagnosis and therapy, a growing number of strategies have been and are being proposed. Compared with other strategies, receptor-mediated drug delivery is most extensively studied lying on several advantages. These systems possess a vital component: nanocarriers modified with targeting moieties. Until now, lots of targeting moieties which are ligands of the receptors on the BBB or glioma have been exploited for BBB-crossing and/or glioma-targeting drug delivery, such as potential peptide ligands. In addition, more and more research has proven that BBB/glioma-specific targeting nanocarrier can help drugs selectively target to the glioma, thus providing higher therapeutic efficiency while simultaneously decreasing systemic toxicity. It seems that the strategy has developed quite well, but so far all the systems except GRN1005 were just used for preclinical studies and none of them have completed Phase II clinical trials. This reminds us that the strategy is still a long way off. It is particularly gratifying that increasing receptors are being found on the BBB or glioma cells, which provide possible targeting sites for developing new receptor-mediated targeting systems. Therefore, extensive research is still required to identify new receptors and corresponding ligands. Most importantly, great efforts should be made to explore and facilitate potential delivery systems for glioma theranosis in future clinical applications.


The DII, a literature-based dietary index to assess the inflammatory properties of diet, was estimated based on a one-day 24-h recall. Multivariable linear and logistic regressions were performed to estimate beta coefficients and the adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs) on the association of pre-pregnancy BMI categories with the DII and CRP concentrations during pregnancy. After controlling for variables including: race/ethnicity, family poverty income ratio, education, marital status, month in pregnancy, and smoking status during pregnancy; women who were obese before pregnancy (n = 136) had increased odds for being in the highest tertile of the DII and CRP concentrations compared to women with normal weight . These findings suggest that women with pre-pregnancy obesity had greater odds of reporting higher DII and having elevated CRP. In conclusion, high pre-pregnancy BMI was associated with increased odds of pro-inflammatory diet and elevated CRP levels during pregnancy in the USA. There have been a limited number of studies examining the association between pre-pregnancy body mass index (BMI) and dietary inflammation during pregnancy. Our aim is to examine the association between pre-pregnancy BMI and the Dietary Inflammatory Index (DII)™ and C-reactive protein (CRP) concentrations during pregnancy. The study included 631 pregnant American women from the National Health and Nutrition Examination Survey (NHANES) cross-sectional examinations from 2003 to 2012. Pre-pregnancy BMI was calculated based on self-reported pre-pregnancy weight and measured height. The cut-offs of <18.5 (underweight), 18.5–24.9 , 25.0–29.9 (overweight), and ≥30 kg/m Pre-pregnancy body mass index (BMI) has been associated with increased risks for adverse pregnancy outcomes such as gestational hypertension, gestational diabetes mellitus (GDM), pre-term birth, and small- and large-for-gestational-age infants . RegardlElevated inflammation during pregnancy may mediate the relationship between weight status before pregnancy and adverse pregnancy outcomes. It has been found that the relationship between pre-pregnancy BMI and the risk of pre-eclampsia was partially mediated by inflammation during pregnancy . ElevateThe Dietary Inflammatory Index (DII)™ was developed to estimate the overall inflammatory effects of diet, and was based on an extensive literature review (around 2000 peer-reviewed articles) ,15. HighDietary patterns considering the overall combinations of food groups and nutrients  among prConsidering that both pre-pregnancy BMI and inflammation are closely associated with dietary factors; it is important to understand how pre-pregnancy BMI is associated with diet-induced inflammation during pregnancy. If the association between pre-pregnancy BMI to inflammation is made clear, it may be possible to reduce inflammation during pregnancy through pre-pregnancy weight status. This will eventually decrease the inflammation and the risk of pregnancy complications as is the main goal under the Healthy People 2020 Maternal and Child Health initiative . It is oOur study utilized public domain data from the continuous National Health and Nutrition Examination Survey (NHANES) 2003–2004, 2005–2006, 2007–2008, 2009–2010, and 2011–2012. The NHANES is a program of biennial data collection designed to assess the health and nutritional status of the civilian, non-institutionalized population of the USA, conducted by the National Center for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC). The NHANES uses a stratified multi-stage probability sample based on the selection of counties, blocks, households, and finally persons within households. The NHANES survey is unique in that it combines in-home interviews and physical examinations conducted at Mobile Examination Centers (MECs). Written informed consent was obtained from each survey participant for both the interview and examination. The participants were interviewed for information regarding age, race/ethnicity, education level, marital status, physical activity, and family poverty income ratio, which is a poverty measure in the poverty guidelines developed by the Department of Health Human Services (HHS) . Reprodun = 61), extreme energy intake values  per day and ≥20920 kJ  per day, n = 9); or missing information on one or more of the following: self-reported weight before pregnancy (n = 23), self-reported height (n = 24), marital status (n = 1), or month in pregnancy (n = 107). The final analytic sample size was 561 pregnant women nt women . The stuκ = 0.78) and to the measured weight in the first trimester (κ = 0.76). A potential recall bias and BMI misclassification level can exist since Cohen’s kappa values were not extremely high. Self-reported pre-pregnancy BMI status was stratified into four categories based on the WHO criteria [2 (obese).Pre-pregnancy BMI was calculated based on self-reported weight before pregnancy and self-reported height. Pre-pregnancy BMI from self-reported height and weight from pregnant women has been validated using the gold reference from multiple imputations . The agrcriteria : <18.5  was measured by latex-enhanced nephelometry by a Behring Nephelometer for quantitative CRP determination ,46,47,48Multivariable models were adjusted for variables that were found to be significantly associated with the DII or pre-pregnancy BMI. Maternal age, family poverty income ratio and month in pregnancy were included in the multivariable models as continuous variables. Maternal education was grouped by the number of completed years of school: Less than high school graduate and more than college level. Race/ethnicity was divided into four groups: Hispanic, non-Hispanic white, non-Hispanic black and other . Smoking status during pregnancy was defined by serum cotinine concentrations .Survey design procedures which considered the complex sampling design of NHANES were used for all analyses . Given that four cycles of 2-year data were used, 10-year sampling weights were developed by multiplying the 2-year weights by 0.2. Descriptive statistics for maternal age, family poverty income ratio, month in pregnancy, race/ethnicity, education, marital status, smoking status during pregnancy, physical activity and parity across categories of pregnancy BMI and DII tertiles were conducted with chi-square tests for categorical variables and an ANOVA test for continuous variables. Beta estimates (95% CIs) for association of pre-pregnancy BMI with the DII and CRP was calculated in both unadjusted and adjusted models. ORs and beta estimates (95% CIs) were calculated for the association between the DII and CRP in both unadjusted and adjusted models. Log-transformed CRP was used as an outcome for linear regression analyses. CRP was dichotomized at >3 mg/L and ≤3 mg/L for logistic regression analyses. p value < 0.05 was declared as statistically significant.ORs and 95% CIs were estimated using logistic regression for the association of pre-pregnancy BMI categories with the DII tertiles and the CRP tertiles, respectively, using unadjusted and adjusted models. In the multivariable model, maternal age (continuous), family poverty income ratio (continuous), month in pregnancy (continuous), race/ethnicity ), education , and smoking status during pregnancy (yes/no) were controlled. Due to missing variables in family poverty income ratio and physical activity, there were 561 pregnant women available for multivariable analyses for the association between pre-pregnancy BMI and the DII tertiles. To investigate the association between pre-pregnancy BMI and CRP tertiles, 551 women were available with CRP values, and 528 pregnant women were available for multivariable models due to missing variables in family poverty income ratio. A test for linear trend was performed using the median approach while calculating the median for each tertile of the DII and CRP, respectively, and as a continuous variable in analyses. A two-sided p < 0.05). There were significant differences in mean DII scores in sociodemographic and lifestyle factors. Pregnant women with greater odds of having a higher DII score  were those with an obese pre-pregnancy BMI. Women with advanced maternal age, Hispanics and non-smokers were less likely to have a higher DII score (p < 0.05).The distribution of study subjects by pre-pregnancy BMI categories and tertiles of the DII is presented in 2 increase in pre-pregnancy BMI was associated with a 0.02 (95% CIs −0.03–4.05) increase in DII during pregnancy and a 0.07 (95% CIs 0.05–0.08) increase in CRP in the covariate-adjusted model.Beta estimates for the association of pre-pregnancy BMI with DII and CRP are presented in ORs and beta estimates for associations between the DII and CRP were calculated , and thep-trend = 0.4112); however, women with obese pre-pregnancy BMIs had increased odds of being in the highest tertile of the DII (pro-inflammatory) compared to women with normal pre-pregnancy BMIs , when adjusted for age, family poverty income ratio, month in pregnancy, race/ethnicity, education, and smoking status during pregnancy. Unadjusted and adjusted ORs for the highest tertile of CRP by pre-pregnancy BMIs are presented in p-trend < 0.0001). Women with overweight and obese pre-pregnancy BMIs had increased odds for being in the highest tertile of CRP in the multivariable model . Unadjusted and adjusted ORs for the highest tertile of the DII by pre-pregnancy BMI are presented in 2) (n = 21) demonstrated a greater pro-inflammatory diet, as indicated by a higher DII score compared to women with a lean pre-pregnancy BMI (18–25 kg/m2) (n = 21)  in a follow-up study from late pregnancy  to 4–10 weeks postpartum.The present study found that pre-pregnancy BMI was associated with the DII during pregnancy in pregnant women in the USA. This was consistent with the previous finding  that aduAs mentioned earlier, one of the most important issues relating to pre-pregnancy BMI and the DII is the quality of diet. Previous studies have examined the relationship between overall the quality of diet and pre-pregnancy BMI ,8,9. Fron = 551) and confirmed the positive significant association between pre-pregnancy BMI and CRP concentrations during pregnancy. Even after adjusting for DII, the beta estimates and standard error for the association between pre-pregnancy BMI and CRP was 0.046 and 0.007 (p < 0.0001), for which the underlying mechanisms are not clearly understood.A strong and positive association between BMI and CRP among various populations such as non-pregnant adults and children has been well established ,54,55. IThe distribution of the DII scores significantly differed according to maternal age, race/ethnicity and smoking status during pregnancy. By using multivariable logistic regressions, the DII was not significantly associated with CRP in our study, which was in contrast with previous findings where significantly increasing values of CRP were found with increasing DII scores, which in turn was associated with all-cause, cardiovascular and cancer mortality ,58. A prThe present study; however, has several strengths. To the best of our knowledge, this is the first study that assessed the inflammatory status based on the diets of pregnant women with respect to pre-pregnancy BMI status. Second, the present study also included CRP as well as the DII to comprehensively assess inflammatory biomarkers and the properties of diet among pregnant women. Finally, various confounding factors  were controlled when examining the relationship of pre-pregnancy BMI with the DII during pregnancy.There were also a few notable limitations in this study. First, only one 24-h recall was used to assess dietary information in the analysis. Using only one day of dietary information may not have accounted for the day-to-day variability in diet, leading to imprecise estimates ; Second,In conclusion, high pre-pregnancy BMI was associated with increased risks of pro-inflammatory diet and elevated CRP levels in pregnant women. Future research is warranted to explore whether increased inflammation in obese pre-pregnancy women may adversely affect offspring health in the long-term.


Identifying optimal, post-operative opioid management strategies is a priority of health providers and government agencies. At present, there are no studies we are aware of that have formally investigated opioid prescribing patterns for post-operative non-arthroplasty orthopedic conditions such as femoroacetabular impingement, nor has any study investigated the influence of opioid prescription patterns on health care costs and utilization. We aimed to investigate a subgrouping scheme associated with post-operative opioid prescription strategies and measure the subgroups’ direct and indirect health care utilization and costs in individuals undergoing non-arthroplasty orthopedic hip surgery.The study was an observational cohort of routine military clinical practices. We used cluster analysis to characterize pre-operative (12 months) and post-operative (24 months) opioid prescription patterns. Linear mixed effects modeling  identified opioid prescription pattern subgroups and identified subgroup differences in health care utilization and costs.Two distinct clusters were identified representing 1) short-duration, high total days’ supply (SD-HD), and 2) long-duration, lesser total days’ supply (LD-LD) post-operative prescription patterns. Significantly higher costs and health care utilization for both hip-related and non-hip-related variables were consistently identified in the SD-HD group.Long-term opioid prescription use has been identified as a concern, but our findings demonstrate that LD-LD post-operative opioid management for hip surgery recipients was associated with lower costs and utilization. Whether these management patterns were a reflection of pre-operative health status, impacted pain-related outcomes, or can be replicated in other orthopedic procedures remains a consideration for future studies.NA. In March 2016, the Centers for Disease Control and Prevention (CDC) published a series of guidelines designed to improve communication between health care practitioners and patients regarding the risks and benefits of opioid drug therapy . WhereasIn addition, whereas immediate pain management strategies for total hip arthroplasty have been well explored peri-operatively , long-teIn light of the recent charge of reducing opioid use published by the CDC  and becaThe study design warranted the use of the REporting of studies Conducted using Observational Routinely collected health Data (RECORD) initiative . RECORD The study was an observational case series of routine clinical practices of Department of Defense (DOD) beneficiaries, seen in both military and civilian network clinics, who received non-arthroplasty hip-related surgery. Data were collected from July 1, 2003, through June 30, 2015, and covered 12-month pre-operative and 24-month post-operative timelines.Data were pulled from the Military Health System Data Repository (MDR), which serves as the centralized data repository for all Defense Health Agency corporate health care data. MDR data are collected from a worldwide network of more than 260 DOD health care facilities and non-DOD entities. Data include every person-level interaction for health care, both inpatient and outpatient. MDR data are carefully processed by the Defense Health Agency, updated monthly, and available to a select group of researchers with special data usage agreements.To keep the sample homogenous, we attempted to identify a specific hip surgical population, FAI syndrome, for which the number of surgeries performed has increased remarkably . Since aTo better understand the pattern of opioid prescription, we a priori clustered two variables: 1) the number of days post-operative to the last opioid prescription (date of last opioid prescription – date of surgery), and 2) the days’ supply variable from MDR, which measures the number of days that the medication covers if taken as prescribed, representing the dose based on a multiple of the strength and daily frequency of each individual intake. Cluster analysis—also called segmentation or taxonomy analysis—is an explorative approach that identifies grouping structures within data . ClusterAge, sex, military service branch, socioeconomic status, hip surgery type (closed or open), and whether the surgery occurred in a network or military health facility were collected to describe the sample. We also examined total health care utilization in the prior 12 months, because the daily number of health care services during the prior year is related to higher use after a specific event such as surgery  . Our heaWe identified a list of medical comorbidities within the MDR that we found to have a significant association with orthopedic injury and surgical outcomes. We captured pre-operative systemic arthropathy , chronic pain, metabolic disorders, substance abuse, insomnia, mental health problems, and post-traumatic stress disorder.We captured variables associated with post-operative health care utilization and costs. In the MDR, costs are sub-categorized by total costs of all health care interventions (which include hip-related and non-hip-related costs) and total costs of hip-related health care interventions—each broken down by provider type. Visits were structured by provider, similarly to costs.We expected a majority of opioid prescriptions peri-operatively (day 0 to day 3). For this study, we were interested in non-acute, post-operative opioid management strategies. Subsequently, we removed all opioid prescriptions that were provided at the index date of surgery through day 3, post-operation. All opioid prescriptions represented in the data are those that occurred from day 4 (post-operative) to month 24.Data in the MDR are processed weekly. Part of the processing involves encounter validation and replacement of missing values prior to release to public consumers, researchers, or policy makers. Within the dataset, 98.11% of cases had complete data and 99.83% of values were complete. Because these missing data were marginal, we opted not to impute data.There were three main analyses used in this study. First, we used two-step cluster analysis to identify post-operative opioid use subgroupings after running pre-clustering methods. This method is designed to reveal natural subgroupings (or clusters) within a dataset that would otherwise not be apparent. Two-step cluster analysis handles scale and ordinal data and automatically selects the number of subgroups using the Bayesian information criterion .Secondly, we used descriptive statistics to describe the groups that were divided by opioid use clusters and comparatively analyzed both groups using SPSS version 23.0. Nominal variables were compared using chi-square analyses. Continuous variables were evaluated using linear mixed effects modeling.p-value < 0.05 was used to determine statistical significance.Lastly, we used linear mixed effects modeling to compare costs and utilization rates between the opioid use-based, clustered groups. Linear mixed effects modeling methods are flexible, model individual change, and accommodate for missing data (when present). We ran two analyses, unadjusted and adjusted, in which we controlled for well-represented baseline characteristics that were significantly different. For all analyses, a N = 850), and 2) long-duration, less total days’ supply (LD-LD: N = 369). The overall trend was that the SD-HD subgroup had more pre-operative comorbidities, opioid prescriptions, and total days of opioid pain medications. That subgroup was also younger and had higher proportions of heavy pre-operative health care utilization. Baseline differences among clustered groups are reported in Table In total, 1219 surgical recipients were included in the planned analyses. Clustering identified two distinct post-operative opioid prescription subgroups: 1) short-duration, high total days’ supply  and indirect  health care utilization and costs. We targeted individuals seeking care in the Military Health System who had undergone non-arthroplasty orthopedic hip surgery in hopes of homogenizing the patient population and care processes. Furthermore, the Military Health System is the closest example of a single-payer system in the United States, which provides an additional advantage when analyzing care-related trends. Rather than attempt to authoritatively define subgroups, cluster analysis identified distinct post-operative prescription patterns as 1) SD-HD and 2) LD-LD. Patient characteristics, costs, and health care utilization were different depending on group allocation, and there are a number of potential reasons for these findings.any form of surgery. For our study, we used Bayesian information criteria to define homogenous subgroups of opioid prescriptions, and two strong, well-defined, distinct patterns emerged. In this cohort, those in the SD-HD subgroup exhibited higher overall health care costs and utilization, whether it was related to the hip or not. In our initial hypothesis, we assumed that longer-term post-operative use would be grouped together with higher doses of opioid prescriptions, but this was not the case when subgroups were determined empirically. Longer-term use was related to fewer overall prescriptions and days’ supply of opioids; and conversely, shorter-term use was related to more prescriptions and days’ total supply. We consider four propositions on the unique patterns that were robustly identified by the subgroups.In the literature, we found no data on post-operative opioid prescription patterns for non-arthroplasty orthopedic hip surgical management and only limited information overall on strategies of opioid prescription patterns for We suggest that the post-operative opioid prescription patterns observed are reflective of pre-operative comorbid conditions. It is well documented that sociodemographic factors, pain, prior drug use, genetics, environmental factors, psychosocial problems, and established addictive behaviors  increase the risk of opioid drug use . ConcomiThe SD-HD subgroup was likely associated with the pre-operative opioid use patterns of its patients. Generalized risks of opioid misuse, abuse, dependence, or addiction are well studied; and prior opioid use also leads to an increase in tolerance of opioids (or a state of adaptation) . Prior eWe hypothesize that those in the LD-LD subgroup may have benefitted more from opioids by receiving adequate pain management, requiring fewer prescriptions over time. Whereas the data regarding the number of pills or strength of dosage related to a prescription were unavailable, we did have data on total days of medication, which is a proxy measure that represents the number of days that the medication covers if taken as prescribed . This interpretation is consistent with our clinical experience and matches the decreased total pain medication days seen in the LD-LD group. This theory deserves further exploration as the idea of greater benefit from longer-term prescriptions is a paradox given the current climate for limiting opioid prescription. For example, on average, LD-LD subgroup patients received opioid prescriptions 400+ days post-operatively; yet, they had lower overall health care utilization and costs.We hypothesize that the higher costs and utilization are associated with increased incidences of side effects in the SD-HD subgroup. Previous work supports that costs associated with opioid-related constipation for non-cancer-related opioid recipients was nearly double that of non-opioid-related constipation, and that inpatient hospitalization odds were 2.3 times higher in those with constipation than in those without . Other sWhat do these findings mean for those prescribing and receiving opioid medications post-operatively? We argue that opioid prescription strategies require further investigation into whether these subgroups replicate in other conditions outside of hip surgery and outside a single-payer system such as the Military Health System. In addition, future work should determine whether these subgroups are related to adequate patient report of pain relief, habituation, or addiction. If these subgroups are represented outside the Military Health System and in other conditions, further exploration is needed to explore why the LD-LD group exhibited less health care utilization and had lower costs.Further, the relationship between true pain relief of the groups should be explored to determination the association of relief to lower utilization and costs. This is especially important since managing long-term opioid prescribing is a targeted objective of the CDC  and the There are several limitations to this study. First, despite our ability to incorporate pre-operative factors and capture patterns over a 24-month period, the study design did not permit cause-and-effect statements to be made about the identified subgroups. Second, the MDR provided no specifics on the type of opioid action (short- or long-acting). Third, the MDR lacks patient-reported outcomes; thus, we are unable to determine which opioid strategy was related to better pain relief and health-related outcomes. Fourth, measures such as chronic pain may fail to represent fully all those with recognized chronic pain conditions. Lastly, the information is limited to individuals within the military payment system and may not be generalizable to other health care environments.Long-term opioid prescription use has been identified as a concern, but our findings demonstrate that LD-LD post-operative opioid management for hip surgery recipients was associated with lower costs and utilization. These results suggest that opioid management strategies for other common post-operative orthopedic procedures should be investigated in a controlled fashion to determine whether this subgroup pattern can be replicated and to better explore the effectiveness of prescription pattern on providing post-operative pain relief without excessive side effects or fostering opioid abuse. Whether these management patterns were a reflection of pre-operative health status, were affected by pain-related outcomes, or can be replicated in other orthopedic procedures remains a necessary consideration for future studies.


Fomitopsis pinicola is a species of Polyporales frequently encountered in Nordic temperate and boreal forests. In nature, the fungus causes destructive brown rot in wood, colonizing tree trunks often occupied by other Basidiomycota species. We mimicked these species-species interactions by introducing F. pinicola to five white rot species, all common saprotrophs of Norway spruce. Hyphal interactions and mycelial growth in various combinations were recorded, while activities of lignocellulose-acting CAZymes and oxidoreductases were followed in co-cultures on two different carbon-source media. Of the species, Phlebia radiata and Trichaptum abietinum were the strongest producers of lignin-modifying oxidoreductases  when evaluated alone, as well as in co-cultures, on the two different growth media . F. pinicola was an outstanding producer of oxalic acid (up to 61 mM), whereas presence of P. radiata prevented acidification of the growth environment in the liquid malt-extract cultures. When enzyme profiles of the species combinations were clustered, time-dependent changes were observed on wood-supplemented medium during the eight weeks of growth. End-point acidity and production of mycelium, oxalic acid and oxidoreductase activities, in turn clustered the fungal combinations into three distinct functional groups, determined by the presence of F. pinicola and P. radiata, by principal component analysis. Our findings indicate that combinations of wood-decay fungi have dramatic dynamic effects on the production of lignocellulose-active enzymes, which may lead to divergent degradative processes of dead wood and forest litter. Fungal interactions are dynamic processes in nature comprising not only pathogen-host and symbiotic relationships, especially with plants, but also microbe-fungal and fungal-fungal interspecies level activities in diverse habitats. Of these habitats, one of the most demanding environments is dead wood . In regaCompetition between fungal hyphae of different species or intraspecies isolates arises from competition of environmental resources, which is demanded by whether the resource territory is already occupied or not . The locIn dead wood, the wood-decaying fungi belonging to Basidiomycota class Agaricomycetes are able to colonize and even decompose compact wood and lignified plant cell walls by production of multiple arrays of carbohydrate active enzymes (CAZymes) and auxiliary oxidoreductases –12. ExprLignin is the most recalcitrant of the plant biopolymers, and it is attacked and modified by oxidoreductase enzymes secreted by the white rot fungi , 14, 19.via Fenton chemistry [Contrary to the white rot Agaricomycetes, it is assumed that brown rot fungi primarily decompose the wood polysaccharides—cellulose and hemicelluloses–non-enzymatically by generating reactive oxygen species hemistry –18,21–22hemistry . Fenton hemistry . Accordihemistry ,15, 24Fungal communities in decaying wood have been investigated by molecular approaches  pinpointing combinations and succession of a few white rot and brown rot species, together with ectomycorrhizal and Ascomycota species, in dead coniferous and deciduous tree species , 25–28. Fomitopsis pinicola  influenced hyphal growth and secretion of extracellular wood-decay enzymes by white rot species of Polyporales  and Hymenochaetales .For these reasons, and taking into account the recent fungal community studies, we designed specific and ecologically justified wood-decay fungal species interaction experiments under laboratory conditions, applying both solid media (agar plates) for detection of hyphal interactions, and coniferous wood-containing semi-solid cultures to follow the effect of different interactions on the production of wood carbohydrate-active and lignin-modifying enzymes. The main purpose was to investigate, how the presence of the brown rot species The selected Agaricomycetes species are well known for their ability to colonize and decompose dead wood, especially Norway spruce, in boreal forests , 31–34 . Our resFomitopsis pinicola, Phlebia radiata, Trichaptum abietinum, and Junghuhnia luteoalba, and two species of the order Hymenochaetales from the genera Phellinus and Porodaedalea  yeast extract (LabM), 2.5% (w/V) agar (Yliopiston Apteekki), and 0.025% (w/V) ABTS  [-1) as mean values with standard deviation.For inspection of mycelial interactions and measurement of hyphal growth rates, cultivations on 2% MEA and ABTS agar plates were initiated for single-species, two-species combinations, and for three-species co-cultures . All culAldrich) . MEA andIn order to follow the effect of fungal interactions on enzyme production and activities, wood-supplemented LN-AS (wood-LNAS medium) and ME broth medium cultivations were conducted in three parallel 100 ml cultures in 250 ml Erlenmeyer flasks, following the same fungal combination scheme . The 2% Production of mycelial mass in the ME broth cultures was determined after eight weeks of cultivation using fiberglass filters (Whatman GFC) and overnight drying at 140°C. Mycelial dry weight was obtained by subtracting the dry weight of the filter from the total dry weight. Acidity  of liquid media cultures was measured at the end of the cultivation. Mean average pH values with standard deviation of three replicate cultures are reported.2+ to Mn3+ malonate chelates [Activities of selected CAZy  glycosidchelates –41. EnzyFungal produced oxalic acid was identified and quantified at the end-point of ME broth cultures applying a UHPLC method optimized for analysis of fungal-produced organic acids from liquid media cultures . HoweverIn order to observe potential correlation of fungal species combination to production of enzyme activities in the wood-LNAS cultures during the eight weeks’ period of cultivation, and to investigate correlation of cultivation end-point data (in the ME broth cultures), principal component analyses (PCA) were conducted using ggplot2 , ggbiplopost hoc tests by using the IBM SPSS Statistics V22.0 package. The normal distribution of the data set at each time point were tested with Shapiro-Wilk test and sphericity were tested with Mauchly’s Sphericity test. Significance of each fungal species as well as the number of species present in the co-cultures, in regard to production of the highest enzyme activities was tested by UNIANOVA and applying Tukey post hoc tests. Significance  of level of confidence over 95% is indicated for the results.The effect of Pr or Ta in regard to production of β-glucosidase activity in the wood-LNAS cultures (time points 4 to 8), were determined using one-way repeated measurements ANOVA together with Tukey P. radiata was the most prominent in mycelial growth pattern  on the MEA reference medium  demonstrated the slowest hyphal extension patterns. In all of the fungal combinations in co-cultures on MEA plates, F. pinicola demonstrated rapid hyphal growth, competing over the white rot species within 17–41 days depending on the fungal combinations  and on MEA  studied (d on MEA . Howeverd on MEA . Contrarf growth . Otherwi studied .-1) were detected with P. radiata (Pr) and T. abietinum (Ta), and in their co-culture combinations with F. pinicola (Fp), on both wood-LNAS and ME broth media  over eight weeks of cultivation, which was observed on both media studied (F. pinicola (combination FpPf).Activity of MnP–assayed as oxidation of MnS medium , but onlS medium . As expeS medium . Two-phaS medium . Noticea studied . HoweverIn case of the white rot species Ta, Jl and Pc, MnP activities were observed when the fungi were cultivated on wood substrate (semi-solid ground wood-LNAS medium), with very low or only occasional activity detected on ME broth  for activity values obtained in single-species and combinatorial cultures on wood-LNAS medium. According to visualization of the computation by PCA, clustering of particular species combinations was noticed on the basis of enzyme activities, with the oxidoreductases (laccase and MnP) directing species clustering whereas the hydrolytic enzyme activities (β-glucosidase and xylanase) determined the second main direction and clustering pattern . In thisP. radiata and T. abietinum together with F. pinicola (FpPrTa) and the two-species cultivation of T. abietinum with F. pinicola (FpTa) were forming a distinct cluster determined by the oxidoreductase activities during weeks 4–7  pH 4.5 value to pH values over 6.0 (up to pH 6.2 with Pf), whereas with Fp single-culture and in the two-species combination FpPc, the wood-based cultures were acidified to around pH 3.2 Fig B in . Of the On the more rich malt-extract (ME) medium, however, a more general acidification occurred in co-cultures with Fp, with final pH values decreasing from the initial (pH 5.5) even as low as to pH 1.7, similar to the values obtained in Fp single-species cultures  and Porodaedalea laricis (formerly Phellinus chrysoloma), either in two- or three-species combinations. Our intention was to record hyphal interactions and also investigate, how mycelial interactions affect production of wood-decaying enzyme activities in submerged and ground-wood supplemented co-cultures on different carbon sources. Quite opposite to the working hypothesis, our results indicate that in co-cultivations of two to three species interacting, the major impact on enzyme activity profiles was noticed to be influenced by two white rot species, namely P. radiata and T. abietinum, while the brown rot species F. pinicola had less or no impact on their enzyme production. Secondly, it was noticed that on coniferous wood substrate, significant variations were observed weekly in lignocellulose-degrading enzyme activity profiles depending on co-culture age and the species combination.In this study, interactions of the brown rot fungus F. pinicola proved to be a supreme colonizer, particularly on malt-extract agar, with hyphae easily extending over the mycelia of the other species studied. Upon these interactions, no visible mycelial blocks were generated against F. pinicola by any of the white rot species studied. This is somewhat surprising, since it has been noted that saprotrophic wood-decaying fungi readily form mycelial blocks upon hyphal confrontations [P. radiata against a few of the other white rot species, but not in all cases. Similar species-dependent variations in pigmentation of hyphal fronts in the interaction strategies have been observed with other white rot fungal species [In regard to mycelial growth patterns on agar media, the isolate of ntations . However species .in situ, in decaying wood in forest sites. The recent long-term surveys in boreal and temperate forests in central and northern Europe, and in Fenno-Scandia, on wood-decay fungal communities and their effects on wood structural and chemical parameters have addressed the dynamics of fungal decomposition of wood [F. pinicola) in boreal forests [It may be assumed that both the quality  and quantity (number of species and isolates in the co-cultures) of fungal combinations would affect production and total activities of the fungal secreted wood-decay enzymes and metabolites. Functional changes and wood-decay processes, however, are difficult to follow  of wood , 26–28.  of wood . Taking  forests , 27.Trametes versicolor, it was reported that in co-cultures with other fungal species, laccase activity may be increased at the mycelial interaction zones in comparison to self-paired mycelia on agar plates [P. radiata and T. abietinum), and laccase activities were also increasing in some combinations including three species. The increase in laccase activities (or laccase production) upon these interactions could be explained by competition for nutritional and habitat resources, or more simply, as a defence reaction following mycelial confrontations [Previously, activities of extracellular wood-decay oxidoreductases, such as laccase, have been observed to change upon interspecies level fungal interactions on liquid media –54. Withntations .P. radiata and T. abietinum, and their summative laccase activity effect observed in three-species co-cultures including Fp. It has been noticed that Basidiomycota fungi which are incapable of laccase production in single cultures, may remain incapable in the presence of other species [F. pinicola as well as Pc  demonstrated no laccase activity either in single-species cultures or in their paired two-species co-cultures. In the case of F. pinicola, this is surprising, since three putative laccase (of the five multicopper oxidase) encoding genes are present in the genome of this brown-rot species [F. pinicola cultivated on poplar wood-containing medium [As can be expected, increased laccase activities have been observed in interactive fungal co-cultures of two white rot fungi that also demonstrate strong laccase production alone, in single cultures . This is species . Accordi species . Howeverg medium . In concg medium , 12.P. radiata and T. abietinum. Strong oxidoreductase encoding gene expression and enzyme protein production burst–involving a set of lignin-attacking class-II peroxidases and hydrogen-peroxide producing oxidases—has been demonstrated to occur in P. radiata when growing in solid-state cultures on spruce wood [P. radiata or T. abietinum or both species, elevated levels of laccase and class-II peroxidase activities indicate on-going strong oxidative, early-phase degradation processes on lignocellulose components and polysaccharides, initiated by the white rot fungal secreted oxidoreductases. The multivariate analyses, as depicted by PCA, accordingly indicated the determinant effect of laccase and MnP production–mainly by P. radiata and T. abietinum—as the main directing factors for phenotype grouping of the fungal combinations.Furthermore, laccase was produced together with MnP activities by the white rot species uce wood . Thus, iF. pinicola was present in all co-culture combinations, which may explain prevention of laccase activity and enzyme production by a few of the white rot species, except for P. radiata and T. abietinum. Surprisingly, no laccase activities were detected for F. pinicola alone (in single-species cultures) on any of the culture media tested, although laccase-like oxidoreductase (ABTS oxidation) activity and protein expression was reported for another isolate of the species [F. pinicola genome sequence [F. pinicola laccase production may be repressed under cultivation conditions adopted in our study.The brown rot Polyporales species  species , and thrsequence . Our ressequence . This imF. pinicola was the highest producer of oxalate (30–61 mM concentrations) as quantified from malt-extract medium cultures after eight weeks of growth, whereas minor concentrations were produced by the white rot species P. radiata (1 mM). Strong production of oxalic acid is a more general ability of brown rot fungi than in white rot species [Apparently, our results indicate that fungal secreted oxalic acid had an impact not only on the culture medium acidity but also on generation of mycelial biomass and hyphal growth.  species –60, and  species .P. radiata prevented acidification to some extent, which may be due to active decomposition of oxalate produced by F. pinicola. P. radiata genome includes several oxalate decarboxylase (ODC) encoding genes [In co-cultures on malt-extract liquid medium, ng genes . Fungal ng genes , 63. No ng genes .P. radiata and T. abietinum, formed their own cluster with Fp, which was driven by similarities in activity levels of laccase and MnP, in the coniferous-wood supplemented co-cultures while the other white rot species clustered together with F. pinicola single-species cultures, with respect to end-point acidity and production of oxalic acid and mycelial mass. On the other hand, some white rot species may be dependent on other fungi for colonization and degradation of their wood substrate environments [Porodaedalea laricis isolate (formerly Phellinus chrysoloma) [F. pinicola and middle-colonizing species Phellinus ferrugineovelutinus, and late-colonizing species Junghuhnia luteoalba   single-sysoloma) , 27. In see also  demonstrF. pinicola in our study, it was surprising to find that white rot species (P. radiata and T. abietinum in particular) were very capable for mycelial cohabitation and hyphal colonization of the same growth environment (agar plates or liquid media flask cultures) with F. pinicola without aggressive or strong combative reactions. On the contrary, in our experiments, these three Polyporales species shared more of a mutualistic than combative growth pattern. It has been noticed in long-term (6 to 12 years) surveys that in the boreal forest site of Norway spruce logs pre-inoculated with F. pinicola, the decaying logs were further occupied by various white rot fungal species–including e.g. T. abietinum and Junghuhnia separabilima–which are more tolerant and competitive for the long-term final degradation of wood [J. luteoalba  was able to coexist together with F. pinicola, as well as with the more robust white rot fungal species P. radiata and T. abietinum.In regard to the superior colonizing ability of the brown rot species rm 6 to 1 years su of wood . AccordiF. pinicola mycelium quickly dominates the white rot species in all combinations, regardless of the number of fungal species introduced. Although F. pinicola hyphae extended in dense white mycelial zones over the hyphae of the white rot fungal species, but simultaneously allowing expansion of the other species’ mycelia, which indicated mutualistic instead of aggressively combating relationships between the fungi studied. The mutualistic or cohabitation strategy was also supported by the fungal enzyme production profiles in co-cultures on the ground-wood supplemented medium, wherein the white rot species P. radiata and T. abietinum at first established oxidoreductase activities (laccase and manganese peroxidase), apparently unaffected by the presence of the brown rot species F. pinicola. On the other hand, a few white rot fungi  caused a slight positive effect on the later production of xylanase and β-glucosidase activities in combination with F. pinicola. These results support that also upon naturally occurring interactions of wood-decay fungi, the rapid oxidative first degradation phase of wood is followed by a later, carbohydrate-active enzyme dominated second decay phase.In this study, hyphal interactions on solid agar media demonstrated that Our results imply that interspecies interactions of Agaricomycetes are dynamic factors to be taken into account when unveiling the fungal and enzymatic decay of wood, and in investigating the role of fungi in recycling of lignocellulosic carbon in the forest ecosystems. Our results also indicate that saprotrophic fungi affect each other in multiple ways in their habitats, thus indicating that the mycelial encounters including several species may in fact be beneficial and even promotive for biodegradation of wood and cycling of forest organic carbon.S1 File(DOC)Click here for additional data file.S2 File(DOC)Click here for additional data file.


Vision problems were the most prevalent health condition, followed by chronic respiratory conditions. Cumulative risk, child executive function, and self-regulation problems in children were uniquely related to child physical health. Homeless children experience problems with cognitive, emotional, and behavioral regulation as well as physical health, occurring in a context of high psychosocial risk. Several aspects of children’s self-regulation predict physical health in 9- to 11-year-old homeless children. Health promotion efforts in homeless families should address individual differences in children’s self-regulation as a resilience factor.Children in homeless families have high levels of adversity and are at risk for behavior problems and chronic health conditions, however little is known about the relationship between cognitive-emotional self-regulation and health among school-aged homeless children. Children ( Family homelessness is an ongoing and pernicious problem in the United States, with about 191,325 people in families staying in shelters at some point during 2010 and 191,903 during 2014, almost 60% of whom were children under 18 [Self-regulation is one factor that buffers the effects of cumulative risk and refers broadly to the capacity of individuals to modify their own behavior, thoughts, and feelings; while executive functions (EF) are a neurocognitive aspect of self-regulation that contribute to the voluntary control of attention and behavior to achieve goals ,8. Self-The question of whether self-regulation/EF and psychosocial risk are associated with physical health during middle childhood is important, because self-regulation is especially malleable during this period due to the pre-adolescent peak in prefrontal gray matter and associated neurodevelopmental shifts that accelerate the development of executive function in the preteen years . Thus, iThe primary aim of this study was to examine how psychosocial risk, self-regulation, and health are related during middle childhood among youth staying in homeless shelters with their families. We hypothesized that child self-regulation, as reflected by EF from parent reports and direct child testing, would be associated with better child physical health.We conducted a cross-sectional study among children living with adult parents or guardians in two large, urban emergency shelters for homeless families in Minneapolis, MN. Parents were compensated with $30 in gift cards and children were given a small age-appropriate toy for their participation. The Institutional Review Board at the University of Minnesota approved the study .We recruited 86 nine to eleven-year-old children residing for >48 h in one of two family homeless shelters that house the majority of sheltered families in the metropolitan area. Parents or children who did not speak English were not eligible, nor were siblings of participants. Children provided written assent, and parents provided written consent. In families with multiple parents, extended family members, or other caregivers, only the person primarily responsible for parenting was invited to participate. One family withdrew prior to assessment. The transient nature of shelter life makes it difficult to calculate the denominator of eligible children; to estimate this, we used shelter census figures on the number of families with a 9, 10, or 11-year-old child staying in each of the shelters at mid-week for each full month of data collection. Using this method, we estimated that 71% of eligible families at each shelter participated.Data was collected in quiet testing suites set up within each shelter. We administered all parent questionnaires via a semi-structured 2-h interview by a trained research associate; a cue card containing visual depictions of scale items was available for each parent-report measure to facilitate understanding. All parent questionnaires were delivered orally given the variability of literacy of parents within this population. Children participated in concurrent one-on-one assessments with another researcher in a neighboring room.We calculated a Cumulative Risk Index based on existing validated measures to account for differences within the high-risk population of homeless families . This inParents were administered the Behavior Rating Inventory of Executive Function-Parent Report (BRIEF) which has high internal validity and test-retest reliability for children aged 5–18 years . The BRIParents reported their children’s Emotional Control using the Social Problems scale from the Child Behavior Checklist , the GloChildren were administered two computerized tasks to examine specific cognitive processes associated with EF and behavioral self-regulation. The Color/Word interference task measured task cognitive flexibility and inhibitory control (“shifting and inhibitory control”), with lower scores indicating more-efficient skills . In the T-scores that are standardized for age and gender, with higher scores indicating better intellectual function.Children were given the Matrix Reasoning subtest from the Wechsler Abbreviated Scale of Intelligence (WASI) , in whicParent-reported child physical health problems and their impact were assessed using the MacArthur Health and Behavior Questionnaire for Late Childhood and Adolescence-Parent form (HBQ-P)  via the p-values and coefficient estimates (β) with standard errors (SE) are reported. All analyses were carried out using the Statistical Analysis System . All p-values are two-sided and evaluated against α = 0.05. We report all results without adjustment for multiple comparisons.Data were first examined for distribution, no variables fell beyond three standard deviations (SD) from means. A review of scatter plots revealed no outliers that were artificially changing the relations between predictor and outcome variables, so all data were included in the analyses. The evaluation of, e.g., q-q plots from each regression, revealed no gross deviations from normal distribution in residuals. Spearman’s correlation coefficients were calculated to determine if there were monotonic bivariate associations between the predictor and outcome variables. Separate multivariable linear regression models were used to test hypotheses regarding adversity/risk and self-regulation/EF predictors of child-reported respiratory symptoms and parent-reported physical health problems after adjusting for child age, sex, and race. Each predictor was examined separately due to multicollinearity among predictors and limited sample size see . p-valuen = 86 total parents, 82 mothers and 4 fathers, mean caregiver age = 33.3 years, range = 25–53 years). Sixty-four percent (64%) of children were identified by their parents as African American, 8.1% Native American, 10.5% biracial or multiracial, and 8.1% another race or ethnicity. Thirty-four of the children had been homeless before, with a mean of 1.8 prior times homeless among these 34 youth . Eighty-six children completed the study. Most primary caregivers were mothers (A majority (70%) of children had at least one parent-reported chronic health condition. Vision problems were the most prevalent single chronic condition . Childrep = 0.213). Child-parent agreement regarding whether or not the child had asthma was moderate (kappa = 0.60). Parent-reported global physical health was correlated with children’s reports of their respiratory symptoms .  was not significantly associated with age, sex, cumulative risk, or health measures, but was associated with direct tests of child EF and inversely associated with parent-reported child metacognition problems. Age was associated with planning/self-monitoring but not inhibitory control. Parent reports and child measures of EF were not correlated with one another. Child-reported respiratory symptoms were not associated with parent-reported chronic medical conditions , parent-reported child EF problems, parent-reported child behavioral regulation problems, and low emotional control. Parent-reported child metacognition problems, child nonverbal IQ, and child task planning/self-monitoring skills did not show unique predictive effects . SimilarAmong this cohort of 9- to 11-year-old children staying in a shelter for homeless families, the mean levels of self-regulation/EF problems as measured by parent report with the BRIEF were overall at or near population-based norms. Nonetheless, those with worse reported health evidenced lower levels on some aspects of self-regulation/EF, consistent with hypotheses based on studies with adults ,34. InhiThere are multiple explanations as to why child health would be related to cognitive and adaptive functioning. These include unidirectional or bidirectional effects of health and adaptive function on one another, and shared causal pathways that might account for problems in multiple domains of biological and social function in development ,34,35,36Additional considerations may help explain the observed associations between EF and health during middle childhood, compared to prior work with younger children, in the context of homelessness ,23. FirsThese results imply an overlap between individual differences in the impact of stress upon children’s self-control and health. This highlights the opportunity for clinical monitoring of, and intervention upon, these possibly bidirectional influences. Child health professionals are well positioned to identify not only risk factors such as toxic stress  and famiOur study is limited by its cross-sectional design. We are thus unable to infer causality or draw conclusions about the longitudinal impact of homelessness upon children’s health and self-regulation. Our small sample limited the statistical power for analyses to test (for example) whether self-regulation might mediate the association between risk and health, or whether the chronicity of homelessness moderates the associations we found. Also, we did not measure all covariates that would be of developmental and health relevance, such as prenatal exposure to alcohol or other drugs. We used standardized measures of health that, while valid and reliable for diverse groups, may fail to detect clinical or sub-clinical conditions in a very high-risk population such as ours. A better understanding of how adversity impacts such measurement would allow researchers to better identify processes vulnerable to context, and to develop intervention and prevention approaches to target specific skills. The results of the current study may not be generalizable; because demographic data on family homelessness and children in emergency shelters is not collected in any systematic manner anywhere in the U.S., we have no data to lend any support to any claims that the homeless population in this metro area is different from, or similar to, any other. However, our study had high ecological validity since assessments were conducted in the shelters where the children and families resided, representing a group of children experiencing acute stress in the form of current homelessness. While there is no direct comparison group in the current study, the use of standardized measures allows for comparisons across normative samples by age and gender. Previous research has established the unique and cumulative effect of homelessness compared to stably housed, poor families, which further supports research within this population regardless of available comparison groups.Our findings suggest that problems with some aspects of self-regulation and health co-occur among homeless school-aged children, highlighting the need for longitudinal research to clarify processes that link these problems. The results also suggest that educational and health care policies may need to support systems that protect children’s cognitive-emotional development regardless of housing status. In addition, it may be important for health promotion efforts with homeless families to assess individual differences in children’s cognitive-affective function, including their abilities to inhibit their impulses and control their behaviors. Specifically, clinicians and educators need to understand the relationship between health and self-regulation, especially among high-risk youth, and provide accurate assessments across markers of development and settings. Pre-adolescent homeless children’s impressions about their physical health differ from their parents’, indicating the need for multi-informant approaches to patient-reported outcomes in this population. Appropriate resources, referrals, and interventions are needed within communities to address health and developmental discrepancies when identified. Finally, it will be crucial to evaluate intervention and prevention programs designed to boost health and self-regulation skills, not only to promote resilience among very high-risk youth, but also to test causal theories on the co-occurrence of self-regulation and health problems in youth from residentially unstable families.