Research findings over the past two decades have supported a link between sleep states and synaptic plasticity. Numerous mechanistic hypotheses have been put forth to explain this relationship. For example, multiple studies have shown structural alterations to synapses  indicative of synaptic weakening after a period of sleep. Direct measures of neuronal activity and synaptic strength support the idea that a period of sleep can reduce synaptic strength. This has led to the synaptic homeostasis hypothesis (SHY), which asserts that during slow wave sleep, synapses are downscaled throughout the brain to counteract net strengthening of network synapses during waking experience . However, neither the cellular mechanisms mediating these synaptic changes, nor the sleep-dependent activity changes driving those cellular events are well-defined. Here we discuss potential cellular and network dynamic mechanisms which could underlie reductions in synaptic strength during sleep. We also discuss recent findings demonstrating circuit-specific synaptic strengthening (rather than weakening) during sleep. Based on these data, we explore the hypothetical role of sleep-associated network activity patterns in driving synaptic strengthening. We propose an alternative to SHY—namely that depending on experience during prior wake, a variety of plasticity mechanisms may operate in the brain during sleep. We conclude that either synaptic strengthening or synaptic weakening can occur across sleep, depending on changes to specific neural circuits (such as gene expression and protein translation) induced by experiences in wake. Clarifying the mechanisms underlying these different forms of sleep-dependent plasticity will significantly advance our understanding of how sleep benefits various cognitive functions. Nearly a hundred years of behavioral research indicates a role for sleep in human cognition. Short-term  sleep deprivation (SD) is known to lead to deficits in performance on memory, sustained attention, and perceptual tasks in human subjects  on the brain may vary with the cognitive demands of an animal's present circumstances. Second, the underlying mechanisms driving sleep-dependent plasticity have been elusive. In part, this is because sleep and wake states alter so many aspects of brain physiology simultaneously—neurotransmission, neuromodulation, transcription, translation, neuronal and network activity, interstitial space and ion concentration, etc. Aton, .Few hypothetical mechanisms have been proposed with an aim toward explaining the many neurocognitive effects of sleep and SD. One notable exception is the sleep and synaptic homeostasis hypothesis (SHY)  during different behavioral states  periods of sleep or SD. These studies assessed changes in mRNA levels in different parts of the brain—hypothalamus  CaMKII is increased by roughly 20–40% in cortical and hippocampal synaptoneurosomes following a 6-h period of SD, relative to a similar period of sleep  periods of sleep and SD on spine turnover. The authors found that across 2 h of SD, total dendritic spine/filopodia density increased by ~5%, while across 2 h of ad lib sleep, it decreased by ~5%. The difference was apparently due to increased elimination rates for existing spines and filopodia during sleep (there was no difference in the rate of new spine formation between sleep and wake). More recently, serial scanning electron microscopy (SEM) was used to reconstruct and measure dendritic spines (and apposed axon termini) in layer 2 of primary motor and somatosensory cortex of juvenile mice after periods of wake (spontaneous or enforced) vs. sleep  synaptic strength. While this measure is indirect, and can also be affected by changes in the intrinsic excitability, many laboratories have used it as a potential indicator of overall synaptic strength  differential effects of sleep on firing in fast-spiking interneurons and pyramidal neurons, one possibility is that excitatory/inhibitory balance  is the major feature of cortical physiology that changes with sleep pressure. In support of this idea, a recent study of the hippocampal neurons' firing across states found the highest ratio of interneuron firing -to- pyramidal neuron firing during active wake  and mice  caused by wake-associated learning. One major caveat is that many of the studies described above  were carried out in adolescent animals  samples come from animals spontaneously asleep or awake at different circadian times, or (2) SD animals used for comparison have been deprived of sleep through environmental enrichment  that was not provided to sleeping animals  are apparently unaffected, while others undergo an apparent reduction in strength.For this reason, more recent descriptions of SHY have proposed that sleep leads to a decrease in the strength modest weakening of at least some synapses can been observed in multiple brain areas across periods of sleep, the function of this for information processing in the brain (if any) is still unknown.Finally, in none of these studies were the observed changes linked with sleep-dependent cognitive function. The animals under study were housed in standard  conditions, and were not being trained on specific learning tasks. While sleep affects numerous aspects of cognition  that are affected by sleep, sleep's effects on these processes have not been linked to synaptic weakening. Thus, while converging data suggest that under steady-state conditions, A past major criticism of SHY is the lack of a specific, sleep-dependent, cellular mechanism mediating the observed biochemical and electrophysiological changes Frank, . Here wein vivo. However, it is necessary to point out that the proposed cellular mechanism is at odds with neurobiological data in two important ways.Recent computational modeling studies from the Tononi lab  with regard to both mechanism of induction and function. While LTD induction requires appropriately timed pre- and post-synaptic firing, and can lead to functional changes within minutes to hours, homeostatic downscaling appears to require increased neuronal firing and acts over a slower timescale of several hours to days. Homeostatic downscaling was first described gluA2 mRNA expression in response to an increase in neuronal activity. CDK5 also interacts with polo like kinase 2 (PLK2) to promote downscaling via downstream effects on the Rap GTPase pathway. This leads to regulation of Rap-mediated changes in AMPA receptor trafficking and dendritic growth , is more active in the brain during the sleep phase of the rodent circadian cycle  that synchronize thalamocortical and hippocampo-cortical activity patterns during NREM sleep  is insufficient for in vivo LTD induction in either the hippocampus  can cause LTD of glutamatergic synapses in vivo, while LTP is more easily induced. In neural circuits where it has been studied, the level of spontaneous activity (which varies with brain state) seems to be a critical variable for both LTD induction and maintenance. For example, LTD can be induced more reliably in the cortex in vivo if animals are deeply anesthetized .It is unclear why many stimulation protocols induce LTD less robustly There is also evidence that over the long term , low-frequency stimulation may also activate the same cellular pathways involved in homeostatic synaptic downscaling.   in the cortex as animals transition from wake to NREM sleep  that sleep and wake affect a variety of cellular processes in both astrocytes   in the context of ocular dominance plasticity (ODP)—a well-studied form of cortical response plasticity initiated by loss of visual input to the cortex from one of the two eyes. ODP is an adaptive response that shifts V1 neurons' visual responsiveness from binocularity to favoring the spared eye. The role of sleep in promoting this process has been studied for nearly two decades. In 2001, Frank et al. initially reported that during a sensitive period of post-natal development, a modest shift in visual responses occurs in cat V1 following a brief (6-h) period of monocular visual experience  occludes subsequent induction of OSRP, and OSRP induction occludes subsequent LTP between LGN and V1  is induced by a loss of visual input, and (2) is most robustly induced during a relatively brief post-natal window, orientation-specific response potentiation (OSRP) is expressed in adulthood in mouse V1 in response to specific patterns of visual input  increases in neuronal firing rate, (2) amplified NREM  oscillations, and (3) phase-locking of neuronal firing to these oscillations. Current data suggest that these changes are the direct result of learning experience during prior wakefulness. We speculate that while synaptic weakening may occur across sleep in the absence of learning , post-learning changes to network activity in the sleeping brain can support synaptic strengthening.SHY proponents have linked synaptic weakening during sleep to NREM oscillations. In the cases described above, however, NREM oscillations  have been linked to synaptic strengthening and growth, resulting in either memory consolidation, adaptive sensory plasticity, or motor learning. Might NREM oscillations differentially affect synaptic strength (bringing it either up or down within a given circuit) depending on prior experience? This is a possibility. Indeed, work from our own lab suggests that this may be the case. One example of this is the firing rate changes that occur in individual V1 neurons after a period in of dark exposure  vs. patterned visual experience. In the former case, an increase is seen across bouts of wake, no change across NREM bouts, and a decrease across REM bouts; in the latter, firing rates increase selectively during NREM and REM sleep bouts (but not wake). Another example comes from the rat somatosensory cortex, where prior experience with a spatio-tactile task (novel object exploration) led to selective increases in firing rate during the next 3 h of subsequent sleep . They also found that presynaptic stimulation patterned to mimic that seen in SWA (but not stimulation patterned to mimic wake activity) led to long-term increases in EPSP amplitude in cortical neurons. A more recent study  following training on a somatosensory perceptual task  or long term (days-long) periods of REM-targeted SD, can disrupt subsequent induction and maintenance of hippocampal CA1 LTP . Preplay maps of place field activation have been reported to predict future trajectories, despite occurring prior to actual experience. Recently, a study by the Foster lab questioned the occurrence of preplay events, suggesting that they may result from a statistical anomaly. Using a larger sample of neurons, and slightly different quantitative methods, the authors were unable to find evidence of preplay events   occur preferentially in the hippocampus during NREM sleep and (2) have themselves been linked to memory formation  or anatomical plasticity  associated with memory consolidation is a technical challenge. A few studies have attempted to resolve whether replay events can be disrupted by NMDA receptor antagonism While a variety of lines of evidence point to a role for sleep in promoting widespread synaptic weakening, two major questions remain unresolved. First, it is unclear whether brain activity patterns associated with either REM or NREM sleep are essential for promoting synaptic weakening, and if so, how this is accomplished. Second and more importantly, it is unclear whether any of the cognitive benefits of sleep are related to this process. Available data from studies addressing the effects of sleep on synaptic function in the context of sleep-dependent episodic or procedural memory formation suggest that strengthening, rather than weakening, could play a key role. However, even in these cases  it remains unclear what aspects of the sleeping brain state are critical for promoting plasticity. Future studies should take advantage of what is known about basic cellular plasticity mechanisms (only some of which are described here) to assess sleep-dependent mechanisms. Recent technical advances in optogenetics, long-term brain imaging, and long-term electrophysiological recording may help link the activity patterns associated with sleep to these specific cellular pathways, to clarify why and how sleep benefits cognition.SA and CP determined the content and wrote 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.


The focal adhesion complex (FAC) has been implicated in the pathogenesis of multiple inflammatory diseases, including IBD, rheumatoid arthritis, and multiple sclerosis. Utilizing omics technologies has proven to be an efficient approach to identify biomarkers from within the FAC in the field of cancer medicine. Predictive biomarkers are paving the way for the success of precision medicine for cancer patients, but inflammatory diseases have lagged behind in this respect. This review explores the current status of biomarker prediction for inflammatory diseases from within the FAC using omics technologies and highlights the benefits of future potential biomarker identification approaches.Inflammatory diseases such as inflammatory bowel disease (IBD) require recurrent invasive tests, including blood tests, radiology, and endoscopic evaluation both to diagnose and assess disease activity, and to determine optimal therapeutic strategies. Simple ‘bedside’  Disease biomarkers have the potential to be medically valuable at all stages of the disease process from diagnosis, identification of disease subtypes, and prognosis to therapeutic adjustment. Inflammatory bowel disease (IBD) is an exemplar of a chronic, complex inflammatory disease. IBD has two major subtypes, ulcerative colitis (UC) and Crohn’s disease, which have different clinical courses and management strategies with a wide phenotypic variability among patients. Biomarkers need to be specific, stable, and consistent across multiple platforms of testing in order to be used as a clinical application. This raises challenges associated with biomarker identification in IBD, as with any complex inflammatory condition, partly due to our limited understanding of the pathogenesis of these diseases and poor appreciation of the difference between what is healthy and what is a disease process. Hypothesis-driven biomarker discovery via traditional one protein–one metabolite or one cell analysis from cellular disease models or tissues compared between control and disease samples is laborious. Such an approach is also limited by the fact that gene expression and signalling of tissues depends on the context and their native environments FACs are dynamic, large protein assemblies that mechanically link and transduce signals from the extracellular matrix to the intracellular milieu via integrins The focal adhesion function is both mechanical and responsive. It is mechanical in terms of anchoring the cell to the extracellular matrix via binding of integrins to their extracellular ligands and to the actin cytoskeleton to modify the physical and topographical characteristics of the cell. This has direct implications for wound healing as well as invasion and the metastatic nature of the cancer cell. The responsive function of the FAC is diverse and multi-layered. Depending on the initiating signal, FAC can be involved in regulating inflammatory gene expression via signal transduction pathways such as interleukin 1 (IL-1) signalling The number of publications listed in PubMed involving FAC  has had a 5-fold increase from 141 published in 1996 to 709 published in 2015. The role of FAC in cancer has been a consistent focus of approximately 44% of publications over the past 20 years . Given tOf the publications identified using the Medical Subject Headings (MeSH) terms ‘cancer’, ‘focal adhesion’, and also adding ‘biomarker’, 39 out of 745 used bioinformatics approaches for biomarker identification. It is of note that all these 39 studies were published after 2007.NLRP3 was identified as a candidate gene for susceptibility of Crohn’s disease The role of FAC in the pathobiology of inflammatory diseases such as IBD or rheumatoid arthritis (RA) has been less well exploited for biomarker discovery. However, the role of FAC in inflammatory diseases can be well illustrated in UC. UC is a relapsing-remitting disease which causes ulceration of the lining of the large bowel and is thought to be a disease of the epithelial barrier The evidence described above has been hypothesis-driven, utilizing mainly cellular models to describe a pathogenic system. In this review we will consider the literature field of FAC in inflammatory diseases focusing on those utilizing a systems medicine approach, where omics data and computational biology are combined for potential biomarker identification.e.g., cell, disease, or treatment) specific data for a signalling system. The challenge of these approaches is that it often requires either a computational biology expert or familiarity with sophisticated computational software solutions to extract biological insights from the datasets In the last two decades, omics technologies have made a great impact on medical research, turning biological research into a data-intensive science Genomic approaches provide the highest number and variety of datasets on human diseases. These approaches include (1) whole-genome or whole-exome sequencing that identify genetic mutations or copy number variations; (2) genome-wide association studies (GWAS) used to identify genetic variants associated with a disease; (3) microarray or RNA-seq techniques for measuring the mRNA or microRNA (miRNA) expression of cells and comparing the levels between states (transcriptomics); and (4) epigenomics analyses focusing on, for example, DNA methylation and its change during differentiation, ageing, and cancer progression. To analyse the genomic datasets of complex diseases, the systems medicine approach is a highly-effective framework to understand the complexity. Disease-related genes may differ among affected individuals, but the affected pathway or network region is likely to be shared In particular, the advent of GWAS identifying candidate susceptibility genes has opened the door to the pathobiology of chronic inflammatory disease. With this, the prospect of a genetic marker for disease diagnosis, prognosis, and therapeutic efficacy in what can otherwise be very heterogeneous diseases is very appealing. GWAS in large populations of patients with chronic inflammatory diseases such as RA can identify common genetic variants that are associated with having that disease Zhang et al. Utilizing GWAS-mapped genes or methylome signatures alone for biomarker prediction has its limitations. Firstly, the differential expression of said genes is not assessed. Secondly, the presence or absence of a single polymorphism within a gene may not have a strong enough phenotype to be a useful biomarker To overcome the potential limitation of not taking into account differential gene expression, He et al. CALM2, miR-19b, and miR181b, for gastric cancer that were related to the FAC and the extracellular matrix receptor. This integrative approach has been, however, less widely used in inflammatory models. For IBD Combinatorial approaches utilizing DEGs and their regulation have been more successful for biomarker discovery. One mechanism of gene regulation is via small non-coding RNAs (ncRNAs) such as miRNAs. miRNAs function in RNA silencing, by base pairing binding of complementary sequences in mRNAs, thus targeting them for cleavage Therefore, despite the central role FAC plays in inflammatory diseases, the number of ncRNAs that could be used as potential biomarkers are still scarce. In the case of UC and Crohn’s disease, miRNAs are the most explored ncRNAs in the literature. There is experimental evidence showing elevated levels of specific miRNAs in active UC tissues and in serum In recent years, many computational methods emerged that allow the analysis of specific ncRNA–disease associations, predict such connections and select the ones most suitable for experimental validation. For example, heterogeneous graph inference for miRNA–disease association prediction (HGIMDA) Protein biomarker identification is driven by better understanding of the disease processes and signalling pathways involved in perpetuation of pathogenic states. Combining large-scale mass spectrometry (MS)-based proteomics and biological network analysis has been fundamental in the understanding of signalling networks Looking again at the cancer model, we can see that integrative approaches using both omics data and computational biology have been successful in producing panel biomarkers for cancer subtypes. A good example of this is reported by Zhang and colleagues Utilizing single omics technologies with computation biology has provided potential markers, but these have often failed to stand up to rigorous validation due to small sample sizes, differences in tissues sampled, or methodological differences. Perhaps a more holistic, integrated approach is needed to meet the needs of modern medicine. This approach towards a more systemic view necessitates obtaining significant insights by adopting a variety of complementary approaches, such as (1) genomics and transcriptional profiling ; and (2) functional and phospho-proteomics (affinity purification and MS), as well as other types of large-scale studies, including lipidomics , chemical proteomics, and compound screening. With the combined and integrated use of these omics approaches, we can identify potential novel biomarkers and drug targets. All biomarkers to be used in clinical practice need independent validation with clinical samples. One such way as used by Szasz et al. The FAC is a large, dynamic, multimeric structural and signalling opportunity for biomarker identification. Cancer research has led the way with FAC members being implicated as biomarkers of invasion The authors certify that they have no conflicts of interest.


Although electronic medication administration record systems have been implemented in settings where nurses work, nursing students commonly lack robust learning opportunities to practice the skills and workflow of digitalized medication administration during their formative education. As a result, nursing students’ performance in administering medication facilitated by technology is often poor. Serious gaming has been recommended as a possible intervention to improve nursing students’ performance with electronic medication administration in nursing education.The objectives of this study are to examine whether the use of a gamified electronic medication administration simulator (1) improves nursing students’ attention to medication administration safety within simulated practice, (2) increases student self-efficacy and knowledge of the medication administration process, and (3) improves motivational and cognitive processing attributes related to student learning in a technology-enabled environment.This study comprised the development of a gamified electronic medication administration record simulator and its evaluation in 2 phases. Phase 1 consists of a prospective, pragmatic randomized controlled trial with second-year baccalaureate nursing students at a Canadian university. Phase 2 consists of qualitative focus group interviews with a cross-section of nursing student participants.The gamified medication administration simulator has been developed, and data collection is currently under way.If the gamified electronic medication administration simulator is found to be effective, it could be used to support other health professional simulated education and scaled more widely in nursing education programs.ClinicalTrials.gov NCT03219151; https://clinicaltrials.gov/show/NCT03219151 (Archived by WebCite at http://www.webcitation.org/6yjBROoDt)RR1-10.2196/9601 Ensuring clinician sciences students have access to appropriate and pedagogically robust clinical learning opportunities is important to generate future cohorts of competent practitioners. The wide-scale adoption of high-fidelity patient simulation tools into clinical education  ,2 is incElectronic medication administration record (eMAR) systems have become more popular in many health care environments over the last decade, as a mechanism to improve medication safety. In brief, an eMAR system is a type of clinical technology that a health care provider  uses to both validate and record the administration of medications. eMAR systems commonly use barcode technology to ensure that the correct medication is being administered to the correct patient at the correct time, dosage, and route . Nurses One significant issue within nursing clinical education is competency and self-efficacy development in safe medication administration practices. Commonly, nursing students receive theoretical courses related to pharmacology and also clinically focused courses during the early years of their undergraduate education. Before students administering medications to real patients, learners usually participate in simulated, in-person learning opportunities within a laboratory setting. In these controlled learning environments, students can practice skills and further integrate their theoretical knowledge of pharmacology with professional practice skills related to medication administration. With recent advances in clinical technology such as eMAR systems , the comThe main objectives of this study are to examine whether the use of an eMAR simulation serious game (1) improves nursing students’ attention to medication administration safety within simulated practice, (2) increases student self-efficacy and knowledge of the medication administration process, and (3) improves motivational  and cognitive processing attributes  related to student learning in a technology-enabled environment. Three specific research questions will be addressed in this study:Does the use of an eMAR simulation game improve the eMAR medication administration safety for nursing students during in-person, simulated clinical practice?Does the use of an eMAR simulation game improve learner self-efficacy and knowledge toward eMAR medication administration processes in nursing students for in-person, simulated clinical practice?Does the use of an eMAR simulation game improve the motivational and cognitive processing attributes of nursing students regarding their learning of eMAR medication administration in a technology-enabled environment?SMART eMAR was designed, developed, and implemented by faculty and students  random number table). Research team members involved in data collection will be blinded to the allocation; participants will become aware of their randomization on receipt of an email from the researchers outlining their allocation into the intervention or control group. At this time, students in the intervention group will receive access to the eMAR simulation game approximately 2 weeks in advance of their in-person simulation sessions with the eMAR technology in the CSL. Along with access to the eMAR simulation game, students in the intervention group will also have access to other usual preparatory educational resources related to medication administration, such as a video demonstrating proper administration technique and a PowerPoint presentation on eMAR medication administration. To ensure a consistent duration of game intervention, students will be requested to use the eMAR simulation game for a minimum of 60 min (with no maximum)  before cThe duration of the active trial in each academic semester will be approximately 4 weeks, running the months of October and February. The simulated return-demonstration patient scenario that all students will be required to complete involves conducting a baseline physical assessment on a high-fidelity human mannequin simulator, performing the ordered medication administration using the SMART eMAR system, and conducting a patient follow-up assessment and documentation of the encounter in the patient’s clinical record. All participants in the intervention and control groups will receive the same patient and medication administration scenario to maximize contextual internal validity.Prepost data related to medication self-efficacy and knowledge will be collected through a Qualtrics  Web-based survey platform before (week 4) and after the simulated return-demonstration patient scenario (week 8). Cross-sectional survey data will be collected from the intervention group only, immediately after the simulated return-demonstration patient scenario week 8; .Data will be collected by 4 data collectors  who will observe nursing student participants during their return demonstration of medication administration using the SMART eMAR (weeks 5-8). These data collectors will be trained by members of the research team before the study initiation to ensure the appropriate and consistent use of the checklist to collect participant data. Mock student return demonstrations and related data collection will be conducted to improve interrater reliability; Fleiss kappa coefficients will be calculated and used to further refine interrater reliability of the data collection procedure. A formalized checklist that has been developed and used previously in an adapted form by the research team  will be The specific questions to be asked during focus group interviews with participants will be informed by the preliminary quantitative findings . Althougt test to compare pre- versus postcontinuous outcomes for intervention and control groups in relation to number of medication errors or near misses, number of deviation from best practices, and length of time (efficiency) of administration will be completed.Survey data will be analyzed through descriptive and inferential statistics. Student Semistructured focus group interviews will be audio recorded and transcribed verbatim. A minimum of 2 researchers will conduct a directed content analysis  of the dEthical approval for this study has been obtained from Western University, London, Canada (HSREB #109180).Preliminary results of half of the desired study cohort is expected in early 2018. By early spring 2018, the findings of the study in its entirety will be available. Currently, data collection of the fall 2017 cohort has concluded.Due to the pragmatic randomized controlled trial design, the findings of this study will establish baselines regarding the effects of serious gaming approaches toward improving nursing students’ eMAR medication administration safety; similarly, the findings will also outline best practices toward the development of immersive gamified simulation opportunities that can be leveraged by other educational organizations. Given the lack of research and consolidated knowledge about this teaching-learning approach , both quCochrane Database of Systematic Review protocol, which plans to examine the effectiveness of serious gaming and other gamified interventions in health professional education [Although still an emerging area of research, there is growing interest toward the development of serious gaming or gamified approaches in clinical education ,39,40. Rducation . As outlducation , this tyAs a strength, this study will be one of the first appropriately powered trials of a serious gaming intervention in nursing education. Furthermore, the pragmatic randomized controlled trial design  with comGiven the potential severity of health outcomes caused by medication errors, nursing education continues to place emphasis on simulated clinical education to provide students with the necessary clinical skills related to medication administration before direct interaction with real patients. Simulation has been widely adopted within clinical education to support medication administration education. However, because of financial and resource constraints experienced by educational institutions, opportunities for students to meaningfully practice eMAR administration continue to be limited. The development of innovative clinical learning strategies such as serious gaming and gamification may offer new opportunities for students to learn these important skills and develop clinical judgment. The findings of this study will generate evidence of a gamified approach to learning in nursing education and provide new pedagogical implications to prepare students with the appropriate skills, knowledge, and competencies related to electronic medication administration.


Healthy People 2020 objective (TU-8) calls for all state Medicaid programs to adopt comprehensive coverage of these treatments.Medicaid enrollees have a higher smoking prevalence than the general population , and smoking-related disease is a major contributor to increasing Medicaid costs . EvidencTo assess state Medicaid tobacco cessation coverage, the American Lung Association compiled data through internet searches of websites and documents. Data sources included Medicaid member websites and handbooks, Medicaid provider websites and handbooks, Medicaid policy manuals, and relevant regulations and legislation. Searches were conducted using search functions on Medicaid and other relevant state-sponsored websites and the Google search engine. Researchers searched for mentions of the nine cessation treatments considered in this study. These data were then confirmed through consultations with staff of state Medicaid agencies, staff of state health departments, or other knowledgeable state government personnel. These consultations were also used to supply missing information and reconcile discrepancies. The information on state Medicaid cessation coverage compiled by the American Lung Association has been added to the CDC State Activities Tracking and Evaluation (STATE) System,Comparing 2008 with 2014, 41 states made changes to the treatments they covered for at least some plans or populations, with 19 states adding treatments to coverage without removing any treatments from coverage, eight states removing treatments from coverage without adding any treatments to coverage, and 14 states both adding and removing treatments . The treInsurance coverage of evidence-based cessation treatments leads to increases in quit attempts, use of cessation treatments, and successful smoking cessation . In partThis analysis indicates that although a number of states have added treatments to their state Medicaid cessation coverage and/or removed barriers to accessing treatments during the period 2008–2014, a number of states have removed treatments and/or added new barriers during this period. Although all states now cover some cessation treatments for at least some Medicaid enrollees, only seven states cover all nine treatments considered in this report for all Medicaid enrollees. All seven of these states still have some barriers in place to accessing some of these treatments. Although more states added treatments to coverage than removed treatments from coverage during the study period, more states added barriers to accessing these treatments than removed them.Several provisions in the 2010 Patient Protection and Affordable Care Act provide opportunities for expanding state Medicaid cessation coverage.¶¶***†††To obtain a full, accurate assessment of a state’s Medicaid cessation coverage and its impact, it is important to consider, not only the cessation treatments covered and the barriers to accessing those treatments, but the extent to which the state Medicaid program promotes the coverage to smokers enrolled in Medicaid and to health-care providers who serve them and the extent to which the coverage is used. The extent to which Medicaid-covered cessation treatments are actually used plays a key role in determining the impact of cessation coverage, and this is driven by promotion and awareness of the coverage. Studies have suggested that many Medicaid enrollees and many physicians who serve them are not aware of their states’ Medicaid cessation coverage  and thatWhat is already known on this topic?Medicaid enrollees smoke at a higher rate than the general population, and smoking-related disease is an important contributor to Medicaid costs. Comprehensive state Medicaid cessation coverage has the potential to reduce smoking rates, smoking-related disease, and health-care costs in the Medicaid population. However, previous reports have found that few states provided such coverage.What is added by this report?Although progress has been achieved in expanding state Medicaid cessation coverage during 2008–2014, this progress has been mixed. During this period, 33 states added one or more treatments to coverage for at least some plans or populations, whereas 22 states removed treatments from coverage. During this same period, 26 states removed barriers to accessing treatments for at least some plans or populations, compared with 29 states that added at least one new barrier. As of 2014, only seven states cover all nine evidence-based cessation treatments considered in this study for all Medicaid enrollees, and none of these states has removed all barriers to accessing these treatments.What are the implications for public health practice?States that cover all evidence-based cessation treatments for all Medicaid enrollees and remove all barriers to accessing these treatments could potentially achieve significant reductions in smoking-related morbidity and health-care costs among Medicaid enrollees. It is also critically important for states to promote their Medicaid cessation coverage to Medicaid smokers and their health-care providers, and to monitor awareness and use of this coverage.The experience of Massachusetts provides an example of the impact that state Medicaid cessation coverage that is widely promoted can have. An evidence-based cessation benefit was heavily promoted to Medicaid enrollees and their providers, achieving high levels of awareness among Medicaid enrollees . MassachThe findings in this report are subject to at least four limitations. First, 2014 data were only partially available for South Dakota. Second, in cases where official documents were not available or conflicted, information on state Medicaid cessation coverage was gathered from knowledgeable state government personnel; this information might have been inaccurate in some cases. Third, cessation coverage can vary widely across Medicaid managed care plans, making it difficult to determine what cessation coverage specific plans provide in practice. Finally, this report does not assess promotion, awareness, or use of state Medicaid cessation coverage. Although examining these factors is essential to accurately evaluate the impact of a state’s Medicaid cessation coverage, the data required to do so are not currently available on an ongoing basis at the national level.Healthy People 2020 target of full coverage in all 50 states and the District of Columbia. States that cover all evidence-based cessation treatments for all Medicaid enrollees and remove barriers to accessing these treatments could substantially reduce smoking rates in a vulnerable population. If states take advantage of its full potential, the provision of the Affordable Care Act that took effect in January 2014 barring state Medicaid programs from excluding cessation medications from coverage might greatly facilitate progress in this regard. States can maximize the impact of their Medicaid cessation coverage by covering counseling as well as medications, promoting their Medicaid cessation benefits, and monitoring awareness and use of these benefits. At present, most states do not appear to be systematically monitoring use of their Medicaid cessation coverage. As indicated by the example from Massachusetts described previously, the fact that most states currently do not provide and promote comprehensive Medicaid cessation coverage is a major missed opportunity to reduce smoking-related morbidity and health-care costs in a population with high smoking rates.The current status of state Medicaid cessation coverage falls well short of the


The multidisciplinary team (MDT) is considered good practice in the management of chronic conditions and is now a well-established part of clinical care in the NHS. There has been a recent drive to have MDTs in the management of women with severe endometriosis requiring complex surgery as a result of recommendations from the European Society for Human Reproduction and Embryology (ESHRE) and British Society for Gynaecological Endoscopy (BSGE). The multidisciplinary approach to the management of patients with endometriosis leads to better results in patient outcomes; however, there are potentially a number of barriers to its implementation and maintenance. This paper aims to review the potential benefits, disadvantages and barriers of the multidisciplinary team in the management of severe endometriosis. Endometriosis is a common non-malignant multi-organ disease characterised by the presence of endometrial glands and stroma outside the uterus. Three clinical presentations of this condition have been described: peritoneal endometriosis, ovarian endometrioma and deep infiltrating endometriosis . Deep inThis aim of this paper is to evaluate the role, benefits, and drawback of multidisciplinary team management of women with deep infiltrating endometriosis. A literature search was performed using the following databases: PubMed, Medline, Ovid and Cochrane for English-language articles published from 1987 till date. The search terms used were various combinations of “multidisciplinary team”, “multidisciplinary approach”, “multidisciplinary care”, “multidisciplinary treatment”, “multidisciplinary meetings”, and deep infiltrating endometriosis. All papers and references were reviewed by the authors and relevant papers identified.Multidisciplinary team work involves coordinated efforts between specialists with expertise in their disciplines in the management of a patient. These MDT meetings ensure higher quality decision-making, reduced incidence of questionable practices, standardised patient care and improved outcomes –10. EndoPreoperative work-up is important in planning a multidisciplinary surgical treatment. Reliably detecting deep infiltrating endometriosis especially in posterior compartment endometriosis could inform surgeons of the need for bowel preparation before surgery and a colorectal surgeon presence at the time of surgery. For the evaluation of bowel endometriosis, physical examination has a limited capacity to diagnose deep infiltrating endometriosis . SeveralCurrently, MRI is not routinely recommended in women with suspected endometriosis but could be particularly useful in detecting rectovaginal and bowel endometriosis –18. AbraA recent systematic review on ureteral endometriosis found that abdominopelvic ultrasound and/or MRI or CT-scan were routinely performed in the initial evaluation. In some studies cystoscopy was also performed when bladder infiltration was suspected .These investigations aims to (1) determine disease location; (2) extent of the disease; (3) planning multidisciplinary team meetings; (4) discuss postoperative care and complications. In our referral centre, all patients with suspected DIE or rectovaginal endometriosis are discussed in our monthly multidisciplinary team meeting attended by the gynaecologist, radiologist, urologist, colorectal surgeon, and the endometriosis nurse specialist where the patient’s history, clinical examination findings and preferences are discussed, images reviewed and a recommendation is made.Laparoscopy is the gold standard used to diagnose and to classify endometriosis . The aimHealthcare professionals also benefit from the multidisciplinary approach for the management of patients. Several studies have shown that it provides a framework for the understanding of the disease process thereby enabling better decision making and providing support for more complex cases . MoreoveOne of the disadvantages of MDT discussions is the lack of patient involvement since patients are not present at these meetings. If patient preferences or social circumstances are not taken into account, team decisions may be inappropriate or rejected. However, patient attendance at these meetings may not be beneficial because of their limited understanding of medical terminology, which may restrict the free flow of information and in addition lead to ineffective input from patients. This may be potentially overcome by the use of questionnaires in the clinic which could guide the MDT in recommending a particular treatment plan best suited to the patient. The effective functioning of an MDT requires constructive input from all team members. A lack of clear roles, objectives and also enthusiasm from its members can hinder the development of constructive management. This does not only have implications for patient care and safety but also has medicolegal implications. All professionals who attend team meetings have a duty of care for decisions made . Clear dAlthough it has been established that multidisciplinary team management improves patient outcome, there are a number of barriers that prevent the full realisation of these benefits. Such barriers include cost, time constraints, and poor interprofessional relationships. The estimated total monthly cost of gynaecological cancer MDTs in the UK is £101,880 . This prTherefore, early referral to a tertiary centre where the appropriate skills and expertise exist to make the correct diagnosis and implement effective management of endometriosis will significantly reduce time to diagnosis and costs.As a minimum, time required to facilitate MDT meetings and treatment plans should be included in job plans to allow an effective high quality service. Poor interprofessional relationship can also affect teamwork and hinder shared responsibility.Although informal discussions already exist in many hospitals, a formalised multidisciplinary preoperative work up and surgical treatment in an endometriosis referral centre is necessary to plan patients counselling and treatment plan implementation which assures improved outcomes. This should be carried out in collaboration with the MDT including a gynaecologist, urologist, colorectal surgeon, specialist nurse, radiologist, pain specialist, counsellors/psychologist and patient support organisations. The success of MDT’s in cancer care should encourage its uptake in benign but chronic conditions such as endometriosis. In future, research should focus on the effect of MDT’s on patient long-term outcomes, cost effectiveness and perception amongst clinicians.


The introduction of diagnostic criteria for vascular dementia has helped to re-define the impact of various subcortical neuropathologies on aging; however, state-of-the-art neuroimaging techniques and autopsy studies suggest that not all structural brain alterations associated with vascular dementia are exclusive to this neurodegenerative process alone. Thus, a detailed analysis of the cognitive phenotype associated with ischaemic vascular disease is key to our understanding of subcortical neuropathology and its associated behaviors. Over the past twenty years, we have operationally defined this cognitive phenotype using the Boston Process Approach to neuropsychological assessment. This has led to both an empirical, as well as a theoretical understanding of three core constructs related to the dysexecutive syndrome associated with ischaemic vascular disease affecting periventricular and deep white matter as well as subcortical structures connecting these regions with the prefrontal cortex. Thus, difficulties with mental set, cognitive control and mental manipulation negatively impact executive functioning. This review will outline the subtle markers underlying this prefrontal dysfunction, i.e., the dysexecutive phenotype, associated with ischaemic vascular disease and relate it to fundamental impairments of gating subserved by basal ganglia-thalamic pathways within and across various dementia syndromes.


Advance care planning (ACP) aids can help prepare patients, family members, and physicians for in-the-moment medical decision-making. We wished to describe the content and approach of paper-based ACP aids in order to characterize existing aids and inform the development of a new ACP aid.Paper-based ACP aids were identified through an environmental scan and screened for eligibility. ACP conceptual frameworks and data were gathered via stakeholder engagement and used to inform the coding framework that two investigators used to independently code each aid. A directed content analysis was conducted on these eligible aids. Aids were categorized through a deliberative process with an investigator abstracting general information for each aid.Fifteen aids met the eligibility criteria. They ranged in length from 6 to 78 pages with the average aid written at an eighth-grade reading level. The content analysis revealed that many aids encouraged choosing a surrogate decision maker and informed users about legal medical documents. Fewer than half of the aids facilitated patient clarification of values regarding quality of life issues. The authors identified and termed the following three categories of aids: informative; semi-action oriented; and action-oriented. It was often unclear whether patients contributed to the development or testing of the ACP aids reviewed.Most existing paper-based ACP aids address legal matters such as completing an advance directive. Only a minority elicited patient values and it was unclear whether any were developed in partnership with patients. Future development of ACP aids should account for patient preferences with a goal of supporting in-the-moment medical decision-making. Advance care planning (ACP) offers individuals the opportunity to clarify their health care goals, concerns, and wishes in preparation for situations where they may be unable to make their own decisions . While An = 15), and have been since explored in more detail [n = 10). Although the preferred aid format might vary based upon characteristics of the patient, provider, and clinical setting [ACP decision aids are designed to facilitate deliberation of preference-based medical decisions, and may benefit patients and alternative decision makers as they prepare to make in-the-moment medical decisions , 8. A ree detail , or were setting , 13, pap setting .While it would be practical for most individuals to initiate ACP prior to becoming ill, evidence indicates that 70% of the general US population do not have advance care plans  in spiteThe purpose of this study was to describe and analyze the content and style of paper-based ACP aids. The study further sought to categorize the aids so as to provide patients and providers with more information that might help to inform their choice of an ACP aid. This work is also anticipated to provide insight into the ways that ACP aids could possibly be designed to further meet the needs of patients, their families, and clinicians as they prepare for possible in-the-moment medical decision-making. Finally, this work could help inform the development of a new ACP tool.Contributing to the environmental scan  to identn = 14) included two patient family advocates, three surgeons, one internist, two health services researchers, four palliative care clinicians and/or researchers, one patient-centered outcomes researcher, and one patient safety and quality researcher. A diverse group of stakeholders were deliberately engaged so as to include a wide-range of perspectives in the discussion surrounding decision aids. Invited participants from each of these stakeholder groups were selected based upon their interest in and experiences with advance care planning, as well as based upon previous work with the research team. Using design-thinking techniques [A stakeholder summit was convened to engage stakeholders and identify relevant elements of paper-based ACP aids. Stakeholders  checklist  to abstrConsistent with a directed content analysis approach  and methContent was coded as pertaining to the clarification of patient priorities and values in general, and specifically in relation to states “worse than death” and patients’ preference for how much leeway a surrogate decision-maker should possess when making decisions on behalf of the patient . Codes wAdditionally, researchers coded information that related to patient discussions about ACP and support for expressing their wishes, including examples of potential ways to start ACP conversations. Finally, the framework also addressed content about legal medical documents and ACP resources, and decisions about after-death issues  –4, 6.The content was described and analyzed qualitatively , 27. CodIn brief, the stakeholders did not recommend the use of content or images that framed ACP from an end-of-life perspective; they felt that end-of-life framing for ACP was “off putting” and could deter patients from engaging with ACP early in their disease course. Stakeholders identified support for patients in choosing a surrogate, opportunities to identify personal priorities, and assistance in enabling patients to imagine states “worse than death.”Of 41 paper-based ACP aids identified, 15 met the inclusion criteria  of the aids scored a one out of four where all of these tools identified the developers’ credentials and/or qualifications. One aid  met two of the four criteria by additionally seeking input from healthcare providers during the development process. It was unclear whether any of the tools had been developed, field-tested, or informed by patient feedback.While not all aids included content from each of the six APC content categories, every aid contained content across more than one category. The following sections describe each of these content categories in more detail.Over half of the aids  explicitly defined ACP. Among these aids, some or all of the following topics were defined as a component of ACP  enabled readers to clarify their role in making health care decisions and contemplation of feelings about potential choices such as “I want to know the basics” or “I want to know as much as I can.” Seven tools  asked patients to imagine different medical or health situations that they could find themselves in and asked patients to specify their advance treatment preferences.The paper-based ACP aids offered patients a variety of opportunities to contemplate and express their values about different aspects of ACP. Nearly half the tools  contained exercises that enabled clarification of priorities and values regarding quality of life with statements such as “In support of communicating patients’ medical wishes, ten aids contained information about ways for patients to start a conversation relating to ACP . The content ranged from example phrases, vignettes, and settings to potential formats  for initiating the ACP conversation (if not in person) and tips for dealing with resistance to that conversation. Beyond offering information about how to start a conversation about ACP, a majority of aids (11/15) also provided information about conversation talking points  did not advocate for or provide assistance with choosing a surrogate. Among the ten that did discuss choosing a surrogate, the type of support ranged from: (i) describing the importance of having a surrogate ; (ii) telling personal stories about choosing a surrogate ; (iii) providing the opportunity to consider different reasons why a person would make a suitable surrogate and comparing individuals across those dimensions . Six of the ten aids also offered patients the opportunity to express how much leeway they were comfortable in granting to surrogates when they were making decisions on the patient’s behalf . Statements within the aids such as “Across all of the paper-based ACP aids, nearly half of the aids  contained content aimed at surrogate decision makers about their roles and responsibility. Additionally, three of the aids provided guidance on making decisions for someone else . Interestingly, some of the aids that did not provide support for designating an alternative decision maker did include information specifically for the surrogate decision maker .Two aids presented information about the odds of survival and presented information about survival statistics for particular treatments . Furthermore, five aids provided users with a description or depiction of different illness trajectories .Almost all of the aids examined in the content analysis  provided information relating to legal and non-legal medical documents. The information included topics such as: (i) explanations of legal medical documents such as advance directives and durable power of attorney of health care; (ii) instructions on how to complete these forms; (iii) treatment definitions that could be of use when completing legal medical documents; (iv) additional resources for where patients could obtain more information; and (v) reminders about when to review and revise medical documents. A minority of aids  also provided opportunities for users to complete wallet cards that specify emergency contact information. The purpose of these wallet cards were such that emergency or medical personal might reference these cards to find the contact information of a surrogate decision maker in the event that the cardholder was unable to speak for her- or himself.The successful implementation of ACP aids could potentially improve the provision of medical care, especially for patients who are more likely to lose medical decision-making capacity.Indeed, the 2015 landmark Institute of Medicine (IOM) report “Dying in America” specifically advocates for more ACP among all patients and their family members . Our stuWhile the reviewed aids were both detailed and informative, the reading level of aids may limit their efficacy. As approximately half of all adults in the U.S. read at or below an eighth grade reading level , the IOMThe content analysis revealed that many stakeholder-identified key components of ACP aids were missing from these paper-based aids. For instance, stakeholders disliked framing ACP from an end-of-life perspective because they felt that this focus could deter patients from engaging with ACP early in their disease course. Yet, most of the examined aids adopted an end-of-life perspective by focusing on legal medical forms and providing information about advance treatment preferences specifically for end-of-life scenarios. Moreover, as some evidence suggests that legal medical documents about advance treatment preferences are limited in terms of their ability to actually inform medical care for patients who cannot speak for themselves , 34–37, ACP conceptual frameworks –4, 6 andInterpretation of these results should take into consideration the study’s limitations. Researchers might have neglected to include useful measures in the development of the coding framework. It was, however, based on components that have been identified previously as meaningful to advance care planning  and to tPatient involvement in the development of these ACP tools was unclear. It is important to gather further stakeholder perspectives and to specifically engage patients and other key stakeholders in the development process of any ACP aid, especially considering that ACP aids should facilitate patient, healthcare professional, and community involvement in decision-making . SubsequThis study identified a need for paper-based aids that support and empower patients to initiate meaningful ACP. All examined aids presented ACP solely within an end-of-life framing. The findings suggest that to meet patients’ needs and create patient-centered ACP aids, active patient involvement is a necessary, and often missing, component and ACP aids need to explore framing beyond specific end-of-life care situations. By identifying and classifying different categories of paper-based ACP aids, the study provides a useful framework that clinicians might use to help inform the selection of an ACP aid that is most appropriate to their patients and to alternative decision makers. Additionally, these findings have helped guide the development of a new ACP aid –41, and


As one of the first defenders of innate immune response, neutrophils make a rapid and robust response against infection or harmful agents. While traditionally regarded as suicidal killers that cause collateral tissue damage, recent findings on neutrophil extracellular trap formation, heterogeneity and plasticity and novel reparative functions have expanded our understanding of their diverse roles in health and disease. This review summarizes our current understanding of neutrophil-associated tissue injury, highlighting the emerging roles of neutrophil extracellular traps. This review will also focus on scrutinizing the roles of neutrophils in tissue repair and regeneration and will examine data on unexpected aspects of involvement of neutrophils in regulating normal tissue homeostasis. Neutrophils are the predominant immune cell in human blood, where they patrol and protect the host from pathogens and other harmful reagents   , which results in the production of chemokines and lipid mediators. ATP-mediated activation of the NLRP3 inflammasome has been associated with persistent neutrophil recruitment, presumably through the release of IL-1 molecules  nuclear appearance ; (2) density; (3) surface receptor expression profiles associated with distinct neutrophil subsets. During the last decade, evidence has been accumulating for the existence of neutrophil subsets in different models, which are briefly summarized in Table  nuclear Although it might be an oversimplified concept, in general, macrophages have been described as having pro-inflammatory M1 and anti-inflammatory M2 phenotypes  has received much attention during the past decade ; however, this situation can be partially reversed by activating the innate immune system. Neutrophils are historically classified as unfavorable actors and have detrimental actions in the CNS (Gadani et al. In one study, the authors sought to address the role of neutrophils in spinal cord injury by depleting neutrophils with antibody. These mice showed worse functional hindlimb recovery and delayed astrocyte reactivity, suggesting that neutrophils have a positive effect on the local glial response. However, as the authors used an antibody that can deplete both neutrophils and monocytes, it remains unclear whether neutrophils are indeed being beneficial. If so, the mechanism of neutrophils-mediated spinal cord injury repair response needs to be further studied (Stirling et al. + extracellular matrix before stromal cells infiltrate and synthesize bone tissue, thus contributing to bone regeneration (Bastian et al. Beside the studies described above, human neutrophils have been shown to rapidly infiltrate the hematoma associated with bone fractures and synthesize fibronectinNeutrophils are short-lived cells under steady condition but, once migrated into tissue, they are exposed to survival signals to increase their life-span. It has long been accepted that, in a successful acute inflammatory response that completely resolves, neutrophils are cleared from inflamed tissue in a timely fashion (Soehnlein and Lindbom With the development of advanced technologies such as intravital imaging, the past decade has clearly been a golden age for neutrophil biology research. Neutrophils have traditionally been considered to cause collateral tissue damage; however, recent studies indicate a clear protective role for neutrophils during resolution and repair. Although there may well be a threshold value at which the positive impact of the neutrophils is adversely affected, from a therapeutic perspective, many of the studies described above provide potential therapeutic targets and approaches other than simply depletion of the neutrophils for the treatment of inflammatory disorders.


Several prestigious agencies routinely rank countries based on crude perinatal and infant mortality rates, while more recently, international neonatal networks have begun comparing neonatal mortality and morbidity rates among very preterm and very low-birth-weight infants. We discuss the methodologic challenges that compromise such comparisons and potential remedies.Crude perinatal mortality rates are biased by international variations in birth registration, especially at the borderline of viability. Such bias is demonstrated by significant differences in crude versus birth weight- and gestational age-specific comparisons of perinatal mortality. Comparisons of neonatal mortality among very preterm and very low-birth-weight infants are plagued by incorrect denominators, and this leads to paradoxical findings.A lack of standardization with regard to birth registration and inadequate appreciation of the methods for calculating gestational age-specific mortality rates are responsible for biasing international comparisons of perinatal mortality. International comparisons of perinatal and infant mortality are appealing for various sociological reasons and can serve to spur improvements in a country’s health system performance. Towards this end, several prestigious institutions such as the UNICEF, the World Bank, and the Organization for Economic Cooperation and Development (OECD) publish annual rankings of countries by rates of stillbirth, infant mortality, and child mortality under 5 years of age –3. TheseProblems with international comparisons of perinatal mortality are not restricted to routine reports published by the UNICEF, the World Bank, the OECD, and related institutions. Serious methodologic issues also plague international comparisons of neonatal mortality that have appeared in scientific medical journals –7. TheseBMJ in 2012 [There is substantial variation in stillbirth registration criteria internationally, and this makes crude comparisons of national stillbirth rates less than meaningful. Most of the variation results from differences in stillbirth registration at the borderline of viability, and thus, rankings of countries based on crude stillbirth rates tend to be substantially different from ranking of countries based on stillbirth rates among births with a birth weight ≥1000 g . Table  in 2012 ; Sweden Comparisons of crude and birth weight-specific neonatal mortality rates show a similar pattern when ranks of countries are based on crude rates vs rates from live births with a birth weight ≥1000 g (or a gestation age ≥28 weeks). In the previously mentioned study , Sweden As mentioned, differences in rankings based on crude versus such birth weight-specific rates of stillbirth and neonatal death reflect international differences in the registration of births at the borderline of viability. In fact, the potential for such bias in international comparisons of fetal and infant mortality rates due to differences in birth registration has been recognized for decades and the World Health Organization (WHO) recommends that international comparisons of infant mortality be restricted to live births with a birth weight ≥1000 g , 21.or ≥500-g birth weight, means that the gestational age criterion will restrict registration to stillbirths with a gestational age of ≥22 weeks, whereas the birth weight criterion will require the registration of variable proportions of stillbirths delivered at 19, 20, 21, 22, 23, and 24 weeks’ gestation , health care culture , and the method of gestational age ascertainment.Evidence for these assertions is seen in variations in stillbirth-to-live birth ratios among births at the borderline of viability within different states in the USA . FurtherTable Contemporary stillbirth registration is based on gestational age at birth or birth weight rather than gestational age or weight at the time of fetal death. This leads to some unexpected birth registration conundrums especially because of new technologies such as fetal reduction for multifetal pregnancy , 24. Fetz score), multiple birth, infant sex, and antenatal corticosteroid use.Several neonatal networks have been created in recent years, with neonatologists championing the collection of data from neonatal intensive care units for quality assurance and research purposes. The development of databases documenting the experience of very preterm infants has facilitated comparisons of neonatal mortality and severe morbidity between centers and also between countries –7. For iSuch neonatal intensive care unit network databases have facilitated the conduct of epidemiologic studies examining the effects of maternal characteristics and interventions among very preterm or very low-birth-weight infants. However, some of the studies based on very preterm or very low-birth-weight subpopulations have shown counterintuitive findings. For instance, one such study  showed tOver four decades ago, Yerushalmy showed that neonatal mortality rates among low-birth-weight infants of mothers who smoked were significantly lower than the neonatal mortality rates among low-birth-weight infants of mothers who did not smoke . This asSeveral solutions have been proposed as explanations for this paradox including one based on the fetuses-at-risk approach, which involves a simple reformulation of denominators for calculating gestational age-specific stillbirth and neonatal death rates. Under this fetuses-at-risk formulation, gestational age-specific stillbirth and gestational age-specific neonatal mortality rates are calculated not based on total births or live births at a particular gestation but on the fetuses at risk for perinatal death at that gestation , 18. ThiOther explanations for the paradoxical perinatal mortality crossover include the relative birth weight hypothesis which postulates that each subpopulation  has a mortality pattern related to its birth weight  distribution . ContrasInternational comparisons of the neonatal mortality among very preterm and very low-birth-weight infants are as seriously flawed as comparisons of neonatal mortality by maternal smoking, hypertensive disorders, and multifetal pregnancy, which are restricted to the preterm subpopulation. The problem with international comparisons of neonatal mortality restricted to the very preterm birth range is illustrated in Fig. The combination of a lack of international standardization with regard to birth registration procedures and practices and the methodologic problems inherent in the traditional model of birth weight- and gestational age-specific perinatal mortality mean that comparisons of perinatal mortality rates between countries can only be valid at a gestational age beyond which complete registration occurs and based on the fetuses-at-risk formulation. The latter approach requires that gestational age-specific perinatal mortality comparisons be made at gestational ages ≥24, ≥26, or ≥28 weeks’ gestation, etc., depending on the gestational age at which complete birth registration is assured.Although restricting the population to a gestational age above which complete registration is assured restores validity to international comparisons of perinatal mortality, it results in the exclusion of a substantial fraction of the population. For instance, in countries such as Canada, over 40% of infant deaths occur among live births <28 weeks’ gestation (birth weight <1000 g) and an international comparison of live births ≥28 weeks’ gestation will exclude this vulnerable population . The enoRoutine reports of the UNICEF, World Bank, and OECD include comparisons of crude fetal and infant mortality without adjustment for extraneous characteristics such as maternal age and parity. If international comparisons of perinatal mortality are motivated by a desire to evaluate perinatal health status and perinatal health services, adjustment for maternal age, parity, and other maternal characteristics would be warranted. On the other hand, the neonatal networks making international comparisons of neonatal mortality among very preterm infants adjust for various extraneous determinants including receipt of antenatal corticosteroids and mode of delivery . PresumaIf the motivation behind international comparisons of perinatal mortality is to assess the relative quality of health services, adjustment for obstetric, neonatal, and other health services would be contraindicated, especially if such services were designed to reduce perinatal mortality. In fact, antenatal corticosteroid administration and mode of delivery lie in the causal pathway between the health care system performance and perinatal mortality. One extraneous health service determinant of perinatal mortality, namely, use of assisted reproduction, presents a conceptual challenge in such analyses—should international comparisons of perinatal mortality adjust for use of assisted reproduction? This technology, which enables infertile couples to achieve their reproductive choices, may require adjustment as it is a marker/risk factor for perinatal death and yet distinct in purpose from other perinatal health care services.Although gestational age considerations are vitally important in ensuring standardized international comparisons of perinatal mortality, there are likely differences in the modality of gestational age ascertainment by country. In most high-income countries, early ultrasound dating is used to resolve problems due to inaccurate gestational age estimates based on menstrual dates. However, not all women receive early ultrasonography, the accuracy of such measurement decreases with advancing gestation, and the proportion of women receiving early ultrasonography likely varies by country. Additionally, there are significant differences in how ultrasonographic measurements are made, and between- and even within-observer variation in measurements is not inconsequential . There iA final consideration in international comparisons of perinatal mortality relates to prenatal diagnosis and pregnancy termination for serious congenital malformations. Although the gestational age at which pregnancy termination is carried out following prenatal diagnosis of a serious congenital anomaly is falling rapidly, a significant fraction of such cases occur in the 20–23 weeks’ gestational age range . ExcludiDifferences in birth registration between countries include differences in birth weight and gestational age criteria and also in the requirement to include or exclude pregnancy terminations (that satisfy birth registration requirements) from stillbirth counts. These differences in birth registration compromise international comparisons of crude perinatal mortality rates. International comparisons of perinatal mortality restricted to births above a specific birth weight or gestational age  yield rankings of perinatal mortality that are substantially different from ranks based on crude comparisons. Although gestational age- and birth weight-specific contrasts of births ≥28 weeks’ gestation or ≥1000-g birth weight yield valid results, they suffer the drawback of excluding a substantial group of vulnerable infants from international comparisons. Comparisons of neonatal mortality among very preterm and very low-birth-weight infants, which are based on information from national neonatal networks, are also compromised because rates are based on incomplete denominators. Use of very preterm or very low-birth-weight live births as the denominator leads to the paradox of intersecting perinatal mortality curves and potentially biased results. Although not universally accepted, the fetuses-at-risk approach addresses this problem but requires a change in denominators to the fetuses at risk of perinatal death at each gestation.In summary, international comparisons of crude perinatal mortality rates, while laudable as a means for spurring improvements in national health care systems, remain compromised currently. Remedial action will require both improved standardization with regard to birth registration issues and also conceptual progress with regard to identifying appropriate denominators for calculating gestational age-specific perinatal mortality rates.


Homo sapiens, Drosophila melanogaster, and Saccharomyces cerevisiae. By leveraging knowledge of functional relationships between genes, we cross-validate predictions on known genetic interactions and observe high predictive power of multiple classes of genetic interactions in all three organisms. Additionally, our method suggests high-confidence candidate interaction pairs that can be directly experimentally tested. A web application is provided for users to query genes for predicted novel genetic interaction partners. Finally, by subsampling the known yeast genetic interaction network, we found that novel genetic interactions are predictable even when knowledge of currently known interactions is minimal.Characterizing genetic interactions is crucial to understanding cellular and organismal response to gene-level perturbations. Such knowledge can inform the selection of candidate disease therapy targets, yet experimentally determining whether genes interact is technically nontrivial and time-consuming. High-fidelity prediction of different classes of genetic interactions in multiple organisms would substantially alleviate this experimental burden. Under the hypothesis that functionally related genes tend to share common genetic interaction partners, we evaluate a computational approach to predict genetic interactions in  Determining the genetic interactions in an organism provides a basis for understanding how the role of a gene is influenced by the action of any other gene. By definition, two or more genes interact when combining variants of each gene produces a significantly pronounced phenotype when compared to the phenotypes of individual variants  and their associated network topological properties guided the training of probabilistic decision trees to predict synthetic sick or lethal (SSL) interactions , fly (Drosophila melanogaster), and yeast (Saccharomyces cerevisiae), and found predictability across different types of genetic interactions. We also investigated how some interactions are enriched in yeast and human gene modules, specifically protein complexes, and the degree to which genetic interactions need to be experimentally determined before enrichment can be found.Here, we examine an algorithm to predict multiple types of genetic interactions across diverse organisms based on the hypothesis that genes strongly participating in shared functions also share common genetic interaction partners. Our approach relies on a functional gene network for a given organism and knowledge of known genetic interactions of a particular type. We tested our approach on three organisms, human  analysis was performed to quantify whether the interaction partners of any given gene are clustered in the organism’s functional gene network. Specifically, for every group of interaction partners of a gene, a score vector consists of entries that are sums of functional network edge weights between each gene in the network to the interaction partners. Because there are no self-edges in the network, leave-one-out cross-validation is carried out on the known interaction partners. An accompanying label vector indicates whether each gene in the network is indeed an interaction partner. The two vectors yield an ROC curve and the corresponding area under the curve (AUC). A seed set’s AUC is the measure of how tightly connected the interaction partners are in the functional network, and therefore how predictive the seed set is for novel interactions  that phenotypically enhances members of the SMAD family and nuclear receptor coactivators yielded an AUC of 0.91. The prediction is that SNW1 also phenotypically enhances with other members of the SMAD family along with members of the forkhead box. In the phenotypic suppression case, we find that known phenotypic suppressors of caspase 2 are tightly functionally linked with members of the BCL2-like family, among other genes. With a resulting AUC of 0.90, these BCL2-like genes are expected to participate in phenotypic suppression with caspase 2.Shown in seven up. From this cluster, genes involved in the sevenless signaling and the Drosophilaepidermal growth factor receptor signal transduction pathways achieved high recall, and neighbor genes also involved in the same signaling pathways are expected to phenotypically enhance seven up. Turning to phenotypic suppression, several Enhancer of split genes are tightly clustered (AUC = 0.98) with known phenotypic suppressors of hairy that include the achaete-scute complex, thereby implicating them as additional, novel phenotypic suppressors of hairy.Similar to the human case, the fly functional network FlyNet is particularly predictive of phenotypic enhancement and suppression, as shown in The full range of various genetic interaction classes that were analyzed from BioGRID are listed in S. cerevisiae .With genetic interactions predicted across multiple organisms, it was natural to investigate their evolutionary conservation. In particular, if a protein complex were enriched in genetic interactions then perhaps a homologous protein complex would also exhibit similar enrichment. We found enrichment of various types of interactions within yeast protein complexes, but none thus far for human. Therefore, instead the problem shifted to identifying the degree to which genetic interactions must be determined in order to find enrichment, and therefore predictability. Using yeast as a test case, simulations successively withheld increasing proportions of genetic interactions, with enrichment within yeast protein complexes computed at each point. The interaction types considered were negative and positive genetic, and synthetic growth defect and lethality. We note that according to BioGRID, negative and positive genetic interactions are reserved for high-throughput assays with growth scores. As shown in S. cerevisiae in particular, predictability was obtained whether the genetic interaction type was based on growth effects or nongrowth phenotype-based measurements . Interestingly, our method did not yield predictability for negative and positive genetic interactions, which happen to be the interaction types for which most of the pairs have been tested . On the other hand, the enrichment signal in synthetic growth defect and lethality is sensitive to the interaction degree, as there was a steep drop-off when most of the interaction pairs were withheld. In the negative and positive genetic networks, there appears to sufficient genetic interaction density such that even when high numbers of interacting pairs are withheld, enrichment under a binomial model can still be found. By extrapolating to the human case, a modest increase in the number of screened human gene pairs is likely to dramatically increase the ability to predict additional genetic interactions, especially for synthetic growth defect and lethality, where the genes have multiple interaction partners.While we did not investigate which classes or properties of functional interactions are predictive of genetic interactions, it would be interesting to further explore such effects. The functional gene network corresponding to a certain organism is an integration of multiple networks from various biological evidence, such as coexpression or protein–protein interactions. It may be informative to hold out certain networks for given evidence classes to determine the resulting effect on the predictability of genetic interactions.Similar to previous genetic interaction prediction approaches , our algAs one major goal of any genetic interaction prediction is to at least narrow down the search space for experimentally testing genetically interacting pairs, our predictions are specifically testable experimentally, perhaps through CRISPR-Cas9 for human cells (http://www.g3journal.org/lookup/suppl/doi:10.1534/g3.116.035915/-/DC1.Supplemental material is available online at Click here for additional data file.Click here for additional data file.Click here for additional data file.Click here for additional data file.


Identifying appropriate preclinical cancer models remains a major challenge in increasing the efficiency of drug development. A potential strategy to improve patient outcomes could be selecting the ‘right’ treatment in preclinical studies performed in patient-derived xenografts (PDXs) obtained by direct implants of surgically resected tumours in mice. These models maintain morphological similarities and recapitulate molecular profiling of the original tumours, thus representing a useful tool in evaluating anticancer drug response. In this review, we will present the state-of-art use of PDXs as a reliable strategy to predict clinical findings. The main advantages and limitations will also be discussed. PDXs maintain the cellular and histological structure of the original tumour and include critical stromal elements, which provide sustenance under periods of extensive growth [In recent years, patient-derived xenografts (PDXs), where tumour fragments from patients are directly implanted in immunodeficient mice and then passed e growth . Moreovee growth , 5. Intee growth , 7. All PDXs are developed by implanting fresh human tumour fragments in immunosuppressed mice. Usually, the time required for the tumour to take is between 2–4 months, although failure of engraftment should not be ascertained until at least 6 months and beyond .F1), tumours initially appeared but a subsequent regression was observed in 3 out 5 mice  nude mice, which lack a thymus and are unable to produce T cells; ii) NOD-SCID and SCID-beige mice, which lack functional T, B and NK cells; iii) NOD-SCID IL2RGamma null , in which the NK cell activity is completely absent. Due to different immunological impairments, it is assumed that the more permissive mouse strains such as NOD-SCID, SCID or NSG, can strongly increase the efficiency of xenotransplantation, as compared to nude mice. Indeed, a very low tumour rate take 10–25%) was reported after implanting tumour fragments of different histotypes in nude mice –10. The –25% was ice Fig. . On the Concerning the tumour engraftment sites, the most common site is the subcutaneous (s.c.) injection of the tumour administered through a small incision made on the dorsal region of the mice. A modification of this classical s.c. procedure has recently been proposed, consisting in the positioning of specimens in a dorsal intramuscular pocket of the mice. The authors reported that in esophageal PDX models this technique produced an improved tumour take-rate (72%) compared to the 17% observed with the standard subcutaneous method , attribuEven though many new antineoplastic compounds have shown favorable tumour responses in preclinical studies, more than 95% of novel therapeutics have failed to confirm efficacy in clinical trials. Many factors are responsible for this high failure rate, including the lack of predictive preclinical cancer models . Thus, gThe study by Bertotti et al.  performeThe need for better, more clinically predictive models of epithelial ovarian cancer which account for 90% of ovarian cancer, led Giavazzi’s group  confirmsIn the search for effective therapies for unresectable gastric cancer, experiments performed on PDXs deriving from 8 patients demonstrated that Regorafenib, a multikinase inhibitor with activity against a range of protein kinases involved in oncogenesis , angiogenesis (VEGFR1–3 and TIE2), and maintenance of the tumour microenvironment (PDGFR and FGFR), was very active in reducing the growth of tumours in mice. Looking at the mechanisms involved in the antitumoral activity of these compounds, the authors reported a reduction in angiogenesis and proliferation associated with apoptosis induction . InteresKRAS genotype for the clinical efficacy of anti-EGFR therapy. In fact, while WT KRAS PDXs were sensitive to Cetuximab treatment [KRAS mutations were unresponsive to the treatment [Notably, PDXs could also be useful models for identifying predictive biomarkers of response to targeted therapies. For example, recently published studies on colon cancer PDXs confirm clinical data regarding the key role of WT reatment , PDXs bereatment  and thesEGFR Exon19 Del. activating mutation responded completely to Gefitinib, while PDXs with KRAS mutations or EGFR wild-types were insensitive to Gefitinib treatment. Even though the authors were not able to report response to Gefitinib in matched patients, these results are consistent with that reported in clinical trials [The utility of PDXs in supporting a precise selection of patients for EGFR-targeted therapies such as Gefitinib has also been demonstrated . These al trials , thus vain vivo preclinical studies and clinical trials could be performed in parallel, with the aim to specifically target the unique cancer of a patient or subgroup of patients. In particular, the concept of co-clinical trials refers to studies capable of defining a patient selection strategy based on molecular abnormalities or identifying mechanisms of resistance to antitumoral therapies, for the development of precision medicine aimed at personalizing anticancer treatment. In this context, PDXs could be also used as an ‘avatar’ model, in which PDXs obtained from a patient enrolled in a clinical trial could be treated with the same therapy administered to the patient, thus permitting to identify biomarkers of sensitivity or resistance to treatments.Evidence showing that PDXs have a high predictive power for the efficacy of standard and novel anticancer therapeutics has encouraged the idea to employ this platform in the so-called co-clinical trials, where in vitro genetic screen and functional studies on CRC showed that dual blockade of EGFR and MEK prevents acquired resistance and as a result performed experiments in vivo on PDXs derived from a CRC patient carrying a quadruple wild-type gene profile  which recapitulate the molecular profile of patients sensitive to anti-EGFR antibodies. Treatment of PDXs with the anti MEK Pimasertib alone only slightly reduced tumour growth, while Cetuximab treatment was very effective in reducing tumours to more than 70%. The subsequent regrowth of these tumours, showed resistance to drug re-challenge thus resembling the clinical findings. In contrast, the Cetuximab/Pimasertib combination elicited a complete response as tumours remained undetectable for more than 6 months. These results led authors to suggest that the use of ‘ab initio’ combination treatment could inhibit the development of resistant tumours showing molecular heterogeneity as well as highlight the usefulness of PDXs in establishing a very effective antitumoral strategy.Most intriguingly, since a major cause of failure of treatments is the acquired resistance of tumours , the useTo search for a second-line personalized treatment in melanoma patients acquiring resistance to BRAF inhibitors, Krepler et al.  establisA paradigmatic example of the use of PDX as an “avatar” for personalized cancer treatment is reported by Bousquet et al. . In partThese examples demonstrate that PDX models integrated with targeted sequencing and phosphoproteomic platforms, provide the preclinical basis for identifying more effective therapies both in the first and second-line targeted inhibitor strategies, also for the repositioning and/or repurposing of previously approved drugs.Although PDXs possess notable advantages compared to classical xenografts as described above, they do have some limitations that cannot be omitted. Importantly, overcoming these issues could increase this model’s potential for improving therapeutic application of antineoplastic compounds.One of the major limitations of PDXs is that tumours fail to progress or to metastasize and therefore do not retain all patterns of the disease course observed in patients. One strategy to overcome this disadvantage is represented by the engraftment of tumour specimens in the orthotopic sites of origin. To this purpose, several reports have shown that patient-derived orthotopic xenografts (PDOXs) could represent a powerful tool for addressing this key point in the science of preclinical modelling. Particularly, DeRose et al.  reportedAt the same time the s.c. implantation does not represent the site of origin, thus limiting studies on evaluating the role of the tumour microenvironment as it is well known that the cells of the tumour vasculature, fibroblasts and inflammatory cells, interacting with tumour cells, are important in tumour biology and that the microenvironment regulates cancer-drug sensitivity . Thus, tA further limitation of the model is that mice used for engraftment have a severely compromised immune system which poses a disadvantage for the full exploitation of PDX technology, since the contribution of immune-cell function hinders the proper evaluation of tumour growth and patient response in these models. This is particularly true in certain tumours such as melanoma in which progresses in treating this neoplasia have been made with targeted immunotherapy , 39. The3) grown in one mouse and implanting small pieces of the mass (15–20 mm3) in several mice for propagation. Our observations seem to confirm this hypothesis as demonstrated in PDXs originating from one colorectal cancer patient and treated with a G-quadruplex (G4) ligand, one mouse showed complete response, two mice partial response followed by a rapid disease progression and no-response was elicited in one mouse (Fig. The intratumour heterogeneity could have an impact on the interpretation of data stemming from PDXs as they are usually developed from small fragments obtained by larger biopsies. At the same time, the passages in mice could increase this spatial intratumoral heterogeneity since propagation is obtained by cutting the tumour mass (300–500 mm mass 15–0 mm3 in One critical aspect concerns the maintenance of PDXs in the genetic integrity of parental tumours and the degree of alterations occurring across the passages into new mice. To this purpose there are many examples throughout literature reporting that in the initial passages, PDXs retain the histological, immunohistochemistry, gene expression, copy numbers and chromosomal stability profile of the original patient tumour , 4. ModiIn contrast, genetic changes that occurred via each passage to a new mouse host seem to represent genomic rearrangements intrinsic to tumour progression. In particular, in breast cancer PDXs it was observed that tumours in mice showed a pronounced mutational status or aggressiveness of tumour characteristics, sometimes comparable to patient metastases compared to primary tumours . These oPerhaps one major obstacle in PDX modelling for co-clinical trials and personalized medicine is the long timeframe required for engraftment. In fact, the tumour latency calculated as the time between implantation and the development of a progressively growing xenograft tumour can range from 2 to 12 months. Considering that tumours have to be passaged several times in mice to generate a sufficient number of “avatars”, this means that individual patients with a rapidly progressing disease could not benefit from PDX studies. To this purpose, performing drug testing in PDXs during the period of standard therapy could be a useful strategy in view of the second-line treatment based on PDXs results.PDX models are a relevant preclinical platform and represent a significant challenge for oncology research as they, more accurately, reflect human tumour biology than any other existing models. If PDXs are viewed as complementary to other experimental models, the use of PDXs should lead to a higher rate of success in identifying new and more effective therapeutic strategies and in transitioning into individualized therapy. The aforementioned limitations of this model, the high costs associated with maintaining mouse colonies and regulatory issues have hindered the full exploitation and widespread utilization of this methodology, therefore vast efforts are needed to refine the model and overcome these challenges. The collaboration between private and public institutes devoted in the fight against cancer, in developing and characterizing large collections of PDX models from different cancer types, will accelerate progress in the area of drug development. In conclusion, the long-term benefits of using more relevant preclinical models of human tumour biology merit these efforts and expenses.


This paper presents adolescent aggression as mediated by the level of differentiation of self. No research has directly addressed Bowen's notion that level of differentiation impacts child functioning including aggression. Level of differentiation is discussed in conjunction with social, gender and cultural norms as manifested in aggressive behavior. Female adolescent aggression is described as mainly relationship focused and expressed via verbal threats, intimidation and manipulation, while male aggression is described mainly as overt physical violence involving dominance and competitiveness. Research on differentiation focuses mainly on Western cultures that tend to be individualistic. Jewish-Israeli society is in transition from collectivistic to individualistic cultural values in the midst of ongoing hostilities. These processes create conflict regarding togetherness and individuality needs among adolescents, who are exposed to contradictory messages regarding separating and staying close. External as well as internal expressions of aggression  are presented as coping strategies in the service of a wounded self-negotiating with the world. Guided mindfulness meditation is a powerful technique for facilitating healing and growth toward autonomy by helping adolescents connect to their inner voice. This technique may be especially useful in the adolescent search for self-awareness, meaning and life purpose. Bodily, cognitive and emotional experiences are treated as informative regarding the “self” and facilitate expansion of self-perception and individuality.