This case report describes false shortening of activated partial thromboplastin time (aPTT) due to erroneous optical reading of the clotting point in the presence of unfractionated heparin (UFH), and a biphasic waveform. Activated partial thromboplastin time performed on a coagulometer with photo-optical detection yielded an ambiguous clotting curve characterized by an early and steady decrease in light transmittance throughout the whole measuring range, with the clotting point read at 65 seconds. Further investigations included measurement of aPTT by means of a mechanical clot detection method as well as determination of another heparin-sensitive coagulation assay, that is thrombin time (TT), both being unmeasurably prolonged (> 150 seconds). Communication with clinicians revealed that the patient was on continuous UFH therapy and had an underlying sepsis, with highly elevated C-reactive protein (289 mg/L). The aPTT measurements requested at three timepoints later during the same day revealed gradual aPTT shortening and unveiled a peculiar biphasic waveform pattern. In this case, unmeasurably prolonged aPTT due to UFH therapy was masked by a biphasic aPTT curve pattern making only the first slope of the biphasic waveform visible within the measuring range. The early decrease in plasma light transmittance mimicked optical changes related to clot formation, thus causing erroneous optical reading and yielding a falsely shortened aPTT. This case emphasizes that such a pattern should be carefully inspected, especially when a combination of a critically ill condition and UFH therapy is present, in order to prevent erroneous reporting of aPTT and potential adverse effects on patient care. Activated partial thromboplastin time (aPTT) is a widely used coagulation test intended for screening of clotting factor deficiencies within intrinsic and common coagulation pathways, for detecting presence of circulating inhibitors such as lupus anticoagulant, and for therapeutic monitoring of unfractionated heparin (UFH). The principle of the test is based on measuring platelet-poor plasma clotting time after addition of contact activators, phospholipids and calcium. The test is nowadays usually performed on fully automated or semiautomated coagulometers with photo-optical or mechanical detection. Clot formation is identified by a change in optical density (OD) of the reaction mixture and aPTT is defined as elapsed time in seconds when the reaction mixture OD has exceeded a predefined threshold  trisodium citrate vacutainer  was promptly delivered to the Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Croatia. Upon receipt, the sample was processed without delay according to standard laboratory operation procedure, Activated partial thromboplastin time determination was performed by coagulometric method using Dade Actin FS and Calcium Chloride  with photo-optical clot-detection system on the Sysmex CS-5100 automated coagulation analyser  according to manufacturer’s recommendations. A normal aPTT measurement curve is shown in Early reaction error: Slow reaction, which raised a suspicion about a non-specific initial decrease in light transmittance and interference in optical reading.An ambiguous aPTT result was obtained and therefore numerical result was omitted and replaced by asterisks (******). The analyser software generated a flag indicating that further review by laboratory staff was required. The clotting point read by the analyser was at 65 seconds . Detailed visual inspection revealed an atypical clotting curve as shown in Therefore, we additionally performed aPTT measurement by a mechanical clot detection method utilizing the semiautomated dual-channel BEHRING Fibrintimer  analyser and using the same reagents as for the optical method. No clot formation was detected and an unmeasurable aPTT was obtained (> 150 seconds).Since the most common cause of aPTT prolongation is heparin presence, we performed another heparin-sensitive coagulation assay - thrombin time (TT). The measurement was done utilizing Test Thrombin reagent  on the Sysmex CS-5100 analyser. An unmeasurably prolonged result was observed .Further investigation of the case, done through communication with clinicians, revealed that the patient was treated with extracorporeal membrane oxygenation (ECMO) after a cardiorespiratory arrest and therefore inevitably required continuous UFH infusion. The patient’s condition was additionally complicated by sepsis, as confirmed by blood culture, and by a markedly elevated C-reactive protein (CRP) of 289 mg/L . Procalcitonin was not requested since it was not needed for case clarification.i.e. 3, 7 and 11 hours after the initial blood draw, with clotting curves as shown in Furthermore, aPTT for the same patient was requested three more times during the same day, Unmeasurably prolonged aPTT due to UFH therapy was masked by a biphasic aPTT curve pattern, making only the first slope of the biphasic waveform visible within the measuring range. Early decrease in plasma light transmittance mimicked optical changes related to clot formation, thus causing erroneous optical reading and yielding a falsely shortened aPTT.2+-dependent macroscopic complex consisting of CRP and very low density lipoprotein (VLDL) that is triggered by recalcification of citrate plasma through addition of aPTT reagents. This immediately causes changes in the reaction mixture OD, reflected as an early drop in light transmittance (Automated coagulation analysers with photo-optical detection measure a change in light transmittance in the reaction mixture during the entire clotting process and yield an appropriate curve. Regular clotting curves have an initial, horizontal plateau with no change in light transmittance, followed by an abrupt decrease once the coagulation process begins due to fibrin polymerisation, ending with a final, steady-state plateau when clot formation is completed, eventually forming a sigmoid-shaped curve (The nowadays less frequently used semiautomated mechanical clot detection method was a valuable alternative in our case since it simply measures the clotting endpoint by detecting changes in the movement of a steel ball or rod in the reaction cuvette, and is therefore not susceptible to optical interferences (A biphasic aPTT clotting curve should be considered when an early and progressive decrease in light transmittance is present.Such pattern should serve as an alert for a possible underlying interference in optical reading that might require manual reading of the clotting point or even adoption of a mechanical clot detection method.Special attention should be given to the combination of a critically ill condition, most commonly sepsis or DIC, and UFH therapy which can result in an ambiguous biphasic aPTT waveform where the slope related to clot formation is not present due to the anticoagulant effect of UFH.Biological interference should not be overlooked as a potential source of preanalytical errors in coagulation testing.


Molluscs are remarkably diverse and are found across nearly all ecosystems, meaning that members of this ancient animal phylum provide a powerful means to study genomic-phenotype connections in a climate change framework. Recent advances in genomic sequencing technologies and genome assembly approaches finally allow the relatively cheap and tractable assembly of high-quality mollusc genome resources. After a brief review of these issues and advances, we use a case-study approach to provide some concrete examples of phenotypic plasticity and genomic adaptation in molluscs in response to environmental factors expected to be influenced by climate change. Our goal is to use molluscs as a “common currency” to demonstrate how organismal and evolutionary biologists can use natural systems to make phenotype-genotype connections in the context of changing environments. In parallel, we emphasize the critical need to collaborate and integrate findings across taxa and disciplines in order to use new data and information to advance our understanding of mollusc biology in the context of global environmental change. We end with a brief synthetic summary of the papers inspired by the 2021 SICB Symposium “Genomic Perspectives in Comparative Physiology of Molluscs: Integration across Disciplines”. Mollusca is the second largest Metazoa phylum, representing over 90,000 extant taxa . MolluscAplysia) are used in biomedical research, while others are important agricultural pests , invasive species , or intermediate vectors of deadly human parasites   .Molluscs have gained recent attention as model species for climate change research. Global climate change is proceeding at an unprecedented rate, with major consequences for all ecosystems. A critical question in this setting whether and how natural populations will respond to global climate change and if these responses will be rapid and adequate enough for species persistence. In general, populations respond to environmental change by one or a combination of four strategies (1) shifting their range, (2) phenotypic plasticity, (3) genetic adaptation via evolution by natural selection to new conditions, and (4) persisting in the original habitat but experiencing demographic decline or extinction .Their high diversity and abundance along with presence across wide latitudinal clines and preservation in the fossil record means that molluscs can serve as a powerful indicator of environmental changes in all ecosystems . MolluscIn the following sections, we will use a case-study approach to provide some concrete examples of phenotypic plasticity and genetic adaptation in molluscs in response to global change . Our surAs is all too common in molluscs, we know comparatively little about phenotypic plasticity and genetic variation and its association—or lack thereof—with phenotypes associated with environmental stress. Most of what we do know has come from a handful of taxa that receive relatively focused attention as model organisms. We here highlight a diverse set of Molluscan taxa that provide illustrative examples of response to various environmental stresses. It is important to note that we were unable to find a substantial body of directly relevant data  from the Molluscan classes Scaphopoda, Monoplacophora, Aplacophora, or Polyplacophora also see , highligPhenotypic plasticity is defined as a situation when a genotype produces different phenotypes in response to different environmental conditions. Phenotypic plasticity is ubiquitous, and most traits are plastic  and plasticity, temperature sensitivity of metabolism, and metabolic cost of heat shock in nine species of nudibranchs collected across a thermal gradient along the northeastern Pacific coast of California. The authors reported that adaptation to relatively warm water temperatures in intertidal nudibranchs constrains plasticity to acute thermal challenge and that southern (warm adapted) species are likely most vulnerable to future warming. Climate-related range expansions were reported during relatively warm periods (between 2014 and 2017) in more than 52 eastern Pacific nudibranch species . Oysters are champions of survival in the face of harsh and dynamically changing environments in estuarine and coastal zones. These habitats experience wide temporal and spatial fluctuations of temperature and salinity, and desiccation presents a serious challenge during daily and seasonal cycles. As reviewed in 3- to 106-fold higher than those of the surrounding water, and are regarded as the most useful model for studying chemical pollution in aquatic environments  instead seem to benefit from expanding hypoxia  is only ∼20% of the control rate  genetic state as well as the adapted/evolved state in the new conditions . There aUnderstanding whether and how organismal populations can adapt to changing environmental conditions requires characterization of intraspecific genetic variation underlying organismal phenotypic variation in relevant environments because this variation provides the raw material for evolution by natural selection . To whatIt is less clear that nucleotide substitution will typically underlie evolutionary adaptation to environmental stresses in molluscs. While we again are limited to very cautious statements in light of the phylogenetically limited scope of relevant data, genomic data from bivalves like scallops  and mussP. antipodarum an especially powerful model system with respect to identifying genetic variation for various phenotypic traits  to global change. Genomic approaches can also help dissect mechanistic underpinnings by which adaptation to climate change occurs  to address genome-to-phenome research.Newly developed genomic technologies and bioinformatic approaches have opened up new opportunities for biologists to address questions of both processes and patterns of organismal change. How can we understand the functional context of such “big” data within the intact organism, and how does genomic variation contribute to phenotype? Our symposium is especially novel from the perspective of bringing together the organismal biologists, ecophysiologists, and genomicists/bioinformaticians that are needed to provide a qualitative step forward in understanding the biology and ecology and predicting the future of one of the most important animal groups alive today. Presentations, discussions, and syntheses focused on topics including overviews of the biological and genomic diversity of molluscan life, technological progress towards highly contiguous molluscan genomes, challenges in assembling molluscan genomes, and how genome-scale processes underpin organismal physiology and interact with ecological and evolutionary processes over multiple spatiotemporal scales can be found throughout the special issue that our symposium inspired.This special issue presents a series of papers addressing mollusc genome-to-phenome responses in the context of global climate change. Connecting genotypes and genomic variation to functional and ecological consequences demands tools and concepts from a diverse set of fields including molecular biology, physiology, quantitative genetics, ecology, and evolutionary biology. This type of integrated approach will help to identify and decouple genetic vs. plastic underpinnings of ecologically relevant functional variation and characterize the ecological consequences of that variation. Our goal for the symposium was to bring together a transdisciplinary set of experts in mollusc biology to provide an unprecedented opportunity for knowledge exchange, discussion, and catalysis of new partnerships. The talks in our symposium featured a wide range of ecologically important concepts and traits including but not limited to immune function and symbiosis to mitochondrial performance and host-parasite interactions, and are united by their use or application of genomic techniques and resources.Ghiselli et al. provide a comprehensive review of one of most striking features of bivalve molluscs: their peculiar mitochondrial genome biology. As Ghiselli et al. describe, bivalves have facultatively anaerobic mitochondria that allow them to survive prolonged periods of anoxia/hypoxia. Molluscs also exhibit the only known and evolutionarily stable exception to the strictly maternal inheritance of mitochondria, so-called doubly uniparental inheritance, now described in 100+ molluscan taxa to date. In this review, the authors highlight recent works studying mitochondrial biology in bivalves at the genomic and physiological level and stress that an integrated approach and collaborative relationships are the only possible ways to succeed in connecting mitochondrial genome-to-phenome relationships in bivalves.Crassostrea virginica) to identify adaptive genetic variation for tolerance to low salinity in two populations from the Gulf of Mexico. The authors compared allele frequencies at 152 salinity-associated genes for larval families pre- and post-low salinity exposure and used these data to demonstrate evidence for purging of deleterious alleles at the larval stage in C. virginica. This study also revealed standing genetic variation for salinity tolerance and demonstrated increases in allele frequencies at multiple loci following selection, indicating a polygenic basis for adaptive responses to low salinity but also suggesting that some components of tolerance are genotype specific.Griffiths et al. used a single-generation selection experiment and pooled sequencing of larvae from the eastern oyster (Phyllaplysia taylori) populations under four temperature-salinity scenarios in a laboratory acclimation experiment. Acclimation to warmer conditions significantly increased critical thermal minima, while low-salinity conditions resulted in high mortality. Individuals that survived the low-salinity treatments were able to respond to temperature and salinity stresses more rapidly than individuals acclimatized to saltier conditions, though the most rapid response time for the low-salinity acclimatized sea hares was at a higher temperature than the individuals acclimatized to saltier conditions. Together, these results led the authors to conclude that acclimation to climate change-induced warming will likely present challenges with respect to the ability of these sea hares to weather existing and predicted cold extremes and precipitation events.Tanner et al. measured thermal plasticity in two central California eelgrass sea hare (Vibrio vulnificus) across four populations of Crassostrea virginica along the North Carolina and Virginia coast. The authors observed significant genetic structure with respect to the distribution of mitochondrial cytochrome oxidase subunit I (COI) haplotypes between locations. The expression of stress-response genes including toll-like receptors, mannose receptor, defensin, and the complement gene Cq3 was specific to locations as well as to the stressors involved. Altogether, these data hint at a complex relationship between genotypes, phenotypes, and stress responses, with indirect evidence for both plasticity and genetic variation for stress responses.Furr et al. explored genetic structure and physiological responses to hypoxia and immune stress challenge , to identify regions of the genome in bobtail squids that are under selection in squid lineages that maintain symbioses with bioluminescent bacteria , setting the stage to identify genes instrumental in the evolution of these mutualistic associations. This study also provided new genomic resources that will be useful for comparative work in cephalopods and beyond.Heath-Heckman and Nishiguchi used newly generated genomic sequence data from four bobtail squid taxa (Our symposium and symposium papers illuminate the power and utility of molluscs as model organisms in a variety of contexts and how organismal and evolutionary biologists can leverage these fascinating organisms to generate new insights into phenotype–genotype connections. These connections are especially relevant and important in the context of anthropogenic change. We believe that we have made a strong case that molluscs can be applied to characterize the potential of and limits to plastic and evolutionary change in response to these planetary consequences of human activities. We also have emphasized the central role that cross-disciplinary collaboration and integration will play in the achievement of these goals.


Frontotemporal degeneration (FTD) is a common cause of young-onset dementia that results in progressive deterioration in executive functioning and social comportment. A tremendous burden is placed on young caregivers, typically spouses, who often sacrifice their own self-care needs in order to manage the cognitive decline and subsequent functional impairments of their loved one, contributing to extraordinarily high levels of stress and depression in caregivers of individuals with FTD. Very few interventions have been tested specifically in FTD caregivers, and those that exist have generally focused on education around patient behavior management. In this session, we will discuss how we adapted the iCare4Me study, originally designed for heart failure caregivers, for caregivers of persons with FTD and we will share initial findings from iCare4Me for FTD, a randomized controlled trial which evaluates the efficacy of a virtual health coach intervention aimed at increasing self-care behaviors and reducing stress in FTD caregivers.


Rhinella marina) to quantify distances moved per day, and the frequency of displacement in their native range (French Guiana) and two invaded areas . We show that toads in their native-range, Hawai’i and eastern Australia are relatively sedentary, while toads dispersing across tropical Australia increased their daily distances travelled from 20 to 200 m per day. That increase reflects an increasing propensity to change diurnal retreat sites every day, as well as to move further during each nocturnal displacement. Daily changes in retreat site evolved earlier than did changes in distances moved per night, indicating a breakdown in philopatry before other movement behaviours were optimised to maximise dispersal.Invasions often accelerate through time, as dispersal-enhancing traits accumulate at the expanding range edge. How does the dispersal behaviour of individual organisms shift to increase rates of population spread? We collate data from 44 radio-tracking studies  of cane toads ( Although the role of environmental and demographic variation is well appreciated, there is also mounting evidence that evolutionary processes contribute strongly to variation in invasion speeds4. For example, deterministic evolutionary processes on invasion fronts select for high rates of dispersal and population growth, causing invasions to accelerate7.The rate at which invasive species spread into new areas determines the timeframe of ecological impact, and is critical for management attempts to buffer those impacts. Thus, understanding factors that influence rates of population expansion is an important challenge. That challenge is complicated by extensive interspecific and intraspecific variation in rates of spread, driven by processes both extrinsic and intrinsic to populations9, through a spatial analogue of natural selection called spatial sorting10. Laboratory experiments have confirmed that prediction13, but field studies generally have relied on less direct evidence. Studies of dispersal rate evolution in free-ranging organisms mostly measure either rates of overall population spread14, or geographic variation in morphological, physiological and behavioural traits that plausibly influence dispersal ability. For example, individuals at an expanding range-edge might have larger wings or longer legs than do conspecifics in range-core populations16. In such studies, the links between phenotype, dispersal, and rate of population spread are either assumed or dependent upon correlational data.Mathematical models predict that individuals at the leading edge of an expanding population will accumulate phenotypic modifications that increase their dispersal ability18 or studies at a single site through time19. As a result, no published studies have enough population-level replication to robustly identify general patterns in rates of dispersal of free-ranging individuals through the course of an invasion. However, we have now studied the spatial ecology of one iconic invader—the cane toad, Rhinella marina—in sufficient detail, in enough places, to fulfil this criterion. Native to South America, toads were translocated to Hawai’i in 1932, and from there to northeastern Australia in 1935—in both cases, to control insect pests of commercial agriculture. In Australia, the toads have since greatly expanded their range across the tropics to the west (moving into increasing hot and arid environments) and along the eastern coast to the south (into cooler climates). The westwards expansion across the tropics has been accompanied by a rapid acceleration in rates of expansion of the geographic range of toads14. In the present paper, we collate and analyse raw data from 44 radio-tracking studies on cane toads in three countries  to explore general patterns of dispersal-relevant behaviour.We can fill in that knowledge gap, at least partly, by gathering empirical data on rates of dispersal of individuals at range-edges compared to range-core regions; but such studies are rare because it is more difficult to measure movement patterns of free-ranging animals than it is to capture those individuals and measure aspects of their phenotype. Even when dispersal rates of free-ranging animals are measured directly, the data typically are restricted to a small number of populations intended to be representative of different phases of the invasion processThe mean distances moved by radio-tracked toads varied considerably among sites, from < 10 m per day in some locations in the native range and Hawai’i, through to more than 200 m per day at the invasion front in tropical Australia  the Australian pattern may have been driven not by increased dispersal on the invasion front, but by reduced dispersal in the long-established parts of the range. Comparison with dispersal rates in the native range (based on studies in both beachside and forested habitats21) now allows confidence as to the direction of evolution in Australia. Previously published information on dispersal in the native range came from Central America, and were based on studies of a toad species now recognised as R. horribilis rather than R. marina23. Based on those reports, the two species may exhibit similarly low vagility in the native range. Although his methods were not directly comparable to ours (reliant on spooling and mark-recapture not telemetry), Bayliss24 recorded modest overall dispersal for cane toads in Amazonian Brazil; net displacements were around 30 m per day, within the range we recorded in French Guiana. Overall, available data support the idea that cane toads within their native range are similar to those in long-established Australian populations. Individuals move nomadically, but their dispersal is constrained to relatively slow, short movements. In Puerto Rico (the stepping-stone population between French Guiana and Hawai’i25), Carpenter and Gillingham26 also reported strong fidelity to water holes in Puerto Rican cane toads.The cline in dispersal rates across northern Australia was first observed some years ago25, has resulted in disjunct populations of toads on the dry (leeward) sides of islands and more continuous distribution on the wetter (windward) sides27. In Hawai’i, the toad population did not have thousands of square kilometres of uncolonised suitable habitat through which to invade. Instead, toad populations on Hawai’i experienced strong environmental gradients associated with elevation and between moist and dry sides of each island. Even in areas with high rainfall, porous volcanic soils restrict the availability of moisture and hence make long-distance dispersal risky27. The strong spatial heterogeneity and limited vacant habitat on Hawai’i likely explains why cane toads have not evolved increased rates of dispersal there  whereas the southern front moved very slowly (< 10 km per annum31). In keeping with those rates of population spread, invasion-front toads in northwestern Australia exhibit rapid dispersal whereas southern (NSW) toads do not.The cane toads that were translocated from Hawai’i to Queensland in 1935 encountered a very different opportunity. Here, there was a vast area of suitable habitat to the west of their introduction point. Arid habitats in southwestern Queensland restricted the toads’ geographic spread to the southwest, leaving possible routes of spread in two main directions—northwest through the tropics to the Northern Territory and then Western Australia; and south along the east coast down into New South Wales6. First, the leading tip of the invasion is a region of low conspecific density and populations experience exponential growth. Here, any trait that increases the reproductive rate is favoured. This is standard r-selection, and can be seen as a race between genetic variants through time. Second, only the most dispersive individuals make it to the leading edge of the invasion in every generation and so only genes that confer high dispersal rates will be on the invasion front. This is spatial sorting and can be seen as a race between genetic variants through space10. On continuous invasion fronts, evolutionary increases in reproductive rate steepen the invasion front and further increase the strength of spatial sorting32.The acceleration in rate of dispersal in northwestern Australia reflects the joint effects of spatial and temporal evolutionary processes33 or in the movements of individual toads  are manifested in all populations of cane toads, even in the native range—but only by some individuals, some of the time36. In the course of their international diaspora, some populations of cane toads—those in northwestern Australia—have shifted to constitutive expression of these previously-facultative traits. All cane toads are capable of rapid dispersal, but exhibit those rates only under specific conditions41. That scenario may be common; for example, Komodo dragons have profound capacities for navigation and movement, despite most individuals never leaving the valley in which they were born42. Given sufficient evolutionary pressure, these latent abilities can become the predominant phenotype: at the tropical Australian invasion front, all toads disperse rapidly, and do so as long as conditions allow it.Importantly, cane toads also adjust their movement patterns to local conditions, with moist conditions increasing the probability of a toad emerging at night from its diurnal retreat20. It is easy to imagine other behavioural traits that would enhance rates of dispersal, such as a preference for moving along open linear corridors rather through dense vegetation40. More detailed studies of cane toads at different stages of the invasion process could explore routes as well as rates of dispersal , and the timing and abiotic correlates of dispersal behaviour (what conditions of darkness and moisture elicit emergence at dusk?).Future work could usefully examine geographic variation in other traits that influence overall rates of dispersal. For example, one of the most efficient ways to disperse long distances is to keep moving in the same direction night after night. Cane toads at the invasion front in tropical northwestern Australia tend to move in this way, and this path straightness is heritable45? In many cases, some level of behavioural shift is required to impose selection on non-behavioural traits. For example, soapberry bugs  likely exhibited at least a partial switch in hostplant preference prior to evolving longer mouthparts that enhanced the bugs’ ability to feed on the invasive plant46, and lizards (Anolis carolinensis) presumably shifted to higher perches following invasion by competitors before evolving morphological adaptations (larger toepads) that facilitate arboreal activity47. Analogously, cane toads appear to have evolved more frequent shifts among refuge-sites prior to evolving enhanced rates of daily dispersal.To evaluate generalities in the evolutionary processes driving rapid evolution during biological invasions, it would also be of interest to examine other examples. Is it generally true, for example, that evolutionary innovation is first driven by changes in behaviour, before morphological and physiological traits evolveIn summary, our data on cane toads provide strong evidence for shifts in dispersal behaviour in the course of a biological invasion. Importantly, we have measured actual rates of dispersal rather than relying upon putative links between an individual’s phenotype and its likely rate of dispersal. Our data reinforce the emerging conclusion that we need to incorporate evolutionary thinking into our approach to wildlife management; the speed and magnitude of shifts in important traits  may be high enough that we ignore them at our peril.Rhinella marina; Bufo marinus in earlier literature) is among the largest anuran species , and is native to northern South America east of the Andes48  with long seasonal migrations52. Studies in Australia suggest that newly-metamorphosed toads are highly philopatric to the natal waterbody until they grow large enough to resist desiccation and thus, can move into the more arid surrounding habitat53. Adult cane toads are primarily inactive by day , within cool moist retreat-sites37. The animals emerge at night to forage, rehydrate and breed40. Because dispersal occurs by night, the linear distance between locations of diurnal retreat-sites used on successive days offers a simple metric of dispersal.The cane toad  in the early nineteenth century, and 150 individuals from Puerto Rico were translocated to Hawai’ian plantations in 1932n = 3–75 toads tracked per site) that we conducted using consistent methods. Adult cane toads were captured in the wild, fitted with small radio-transmitters on waist belts , released at the site of capture, and then relocated on a daily basis (where possible) for at least 5 days thereafter. We did not include data from spool-tracking studies57, or from studies with longer intervals between relocations39. Most of the studies were conducted by members of the same research group, over a 16-year period (2005 to 2020). In some cases, studies were conducted at the same sites several years apart, and hence with different times since initial colonisation by toads. All studies were conducted during weather conditions that facilitate toad activity , and we excluded data from toads that had been subjected to experimental treatments  that might change their dispersal behaviour.We compiled original data from 44 radio-tracking studies  mean distance moved per day  and (2) the proportion of nights that the toad changed diurnal retreat-sites . From these two variables we also calculated (3) daily distance moved in cases where the toad changed shelter-sites .This paper is based on a collation of data from previous research; no additional animals were handled in the course of the current work. In the original studies, all experimental protocols were approved by institutional committees  and were conducted in accordance with all relevant guidelines and regulations, including the ARRIVE guidelines.60). Table We classified each study site in terms of time since invasion by toads (based on historical records


Registered nurses (RNs) are a key component of the long-term care (LTC) workforce and prior research demonstrates their importance to ensuring patient safety in LTC settings. RNs who work in LTC settings earn less than those who work in hospitals and also are more likely to be from racial and ethnic minority groups. This study seeks to measure wage differences between Registered Nurses (RNs) working in LTC and other settings  and whether differences are associated with the characteristics of the RN workforce between and within settings. We used the 2018 National Sample Survey of Registered Nurses (NSSRN) public-use file to examine RN employment and earnings. Our study population included a sample of 15,373 employed RNs who provided patient care. Characteristics such as race/ethnicity, type of RN degree completed, census region, and union status were included in bivariate analyses and multiple regression analyses to examine the effect of these characteristics on wages. Logistic regression was used to predict RN employment in LTC settings. We found that RNs in LTC experienced lower wages compared to those in non-LTC settings, yet this difference was not associated with racial/ethnic or international educational differences. LTC nurses were also significantly less likely to be represented by a labor union, and there was not a statistically significant wage difference for LTC RNs who were unionized. Because RNs in LTC earn lower wages than RNs in other settings, policies to minimize pay inequities are needed to support the RN workforce caring for frail older adults.


The possible implications of physical activity during the period of pregnancy have been much debated over recent decades. This brief appraisal integrates knowledge from an array of position papers, systematic reviews, meta-analyses, and recommendations provided by specialty board committees. The medical community is becoming more and more aware of the beneficial effects of mild and moderate physical activity on the mother and the fetus, including improved clinical correlates of subsequent vaginal delivery, as contrasted to the clearly unbeneficial effects of a sedentary lifestyle. Pregnancy is associated with considerable physiological and psychological changes that may promote sedentary behavior in women. Such behavior is associated with increased risks for gestational diabetes, arterial hypertension and excessive weight gain, all of them jeopardizing maternal and fetal well-being in pregnancy.Since at present a large proportion of pregnant women engage in regular physical activity during pregnancy, it is imperative that the obstetrician becomes familiar with the effects that physical activity can exert on maternal health and pregnancy outcomes.th Century B.C.E.) and later Plutarch of Chaeronea (1st/2nd Century C.E.) urged Spartan and other Greek women to exercise in order to decrease the pain of childbearing [The debate with regard to the possible risks and benefits of physical activity during pregnancy goes back to biblical times when Hebrew writers observed that slaves had much easier deliveries than their Egyptian patrons who led a sedentary life . Both Arth century pregnant women were encouraged to remain indoors, keep themselves “confined”, and advised to avoid exercise since “during gymnastics there was a risk that the female organs might slip when straddling and female fertility may be at severe risk“ [In contrast, it is amazing that by the end of the 19re risk“ .th century, the advances in knowledge of anatomy and physiology led to a dramatic change in the approach to physical activity in general and during pregnancy in particular. Already in the 1930’s antenatal exercise classes taught by Heardman, a physiotherapist, were introduced in England and Sweden [During the 20d Sweden . The LamIn 2015, the American College of Obstetricians and Gynecologists published a Committee Opinion with regard to physical activity and exercise during pregnancy and the postpartum period. The Committee recommended that pregnant women with no risk factors should exercise 20-30 minutes per day engaging in aerobic and strength-conditioning exercise before, during, and after pregnancy [Overall, the last 100 years witnessed a great interest in this subject as evidenced by an enormous bulk of literature published in the most prestigious medical journals. Below, we present a personal selection of some of these reports.et al. quote the U.S. Department of Health and Human Services definition of “physical activity” that it is “defined as any bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above a basal level”. In contrast, “exercise” represents “a form of physical activity that is planned, structured, repetitive, and performed with the goal of improving health or fitness” [Szumilewicz fitness” .The results of a detailed literature review on the physiology of exercise in pregnancy were, among others, that :–maximal aerobic power is well-preserved in pregnant women who remain physically active;–in contrast, anaerobic working capacity may be reduced in late gestation;–responses to prolonged submaximal exercise (>30 minutes) in late gestation include a moderate reduction in maternal blood glucose concentration, which may transiently reduce fetal glucose availability;–the normal response to sustained submaximal  exercise is an increase in fetal heart rate (FHR) baseline;–transient reductions in FHR reactivity, fetal breathing movements, and FHR variability may also occur in association with more strenuous exercise.Consequently, Wolfe and Weissgerber stated that healthy women undergoing normal pregnancies can participate safely in moderate prenatal fitness programs and maintain or improve physical fitness without harming fetal growth and development .During pregnancy, sustained exercise sessions cause an intermittent reduction in oxygen and substrate delivery to the interphase that may exceed 50% during the exercise, however, regular bouts of sustained exercise or exercise training probably improve oxygen and substrate delivery to the fetus at rest .As to work effciency, the energy cost of standard submaximal exercise in pregnancy depends on whether the activity is weight-bearing or weight-supported. For weight-supported exercise (such as cycling), the energy requirement above resting metabolic rate is not significantly affected by pregnancy or advancing gestational age. In contrast, for weight-bearing activities , the energy requirement increases in proportion to maternal weight gain .Swimming has been advocated as an optimal exercise during pregnancy due to its buoyant effects and the thermally conductive properties of water . Stationet al. data [From a systematic review, the exercise intensity prescription should be mild to moderate for previously sedentary women, and moderate to high for previously active women . Thus, mal. data  where ital. data , consistAbsolute and relative medical contraindications to exercise during pregnancy are given in Since it seems possible to improve pregnancy outcomes in both healthy, low-risk women and a variety of high-risk populaces by simply modifying maternal physical activity and dietary carbohydrate intake during pregnancy , this noet al. [The majority of women who gained excessive weight are at risk of developing gestational diabetes and preeclampsia, and of having macrosomic babies, all of which can lead to increased complications in labor and delivery. Furthermore, these big babies born to overweight mothers are at a significant risk for developing type 2 diabetes later in life. Thus, it is of importance that in their robust meta-analysis which included 442 studies addressing the effect of exercise on pregnancy, Tobias et al.  concludeet al. . In a Caet al. .Other pregnancy-related complications which may seriously jeopardize the pregnancy outcome are hypertensive disorders. They affect about 3-9% of all pregnancies worldwide, with preeclampsia diagnosed in 2-4% of them. Even today hypertensive disorders are one of the main causes of maternal and fetal morbidity and mortality . TherefoRegarding other central clinical correlates, one of the main fears of the pregnant patient is that physical activity may increase her risk for miscarriage or premature delivery. Most studies addressing this question state that in a patient with no risk factors  physical activity is safe. However, one should advise against exertion (high-intensity and long-duration exercise) in early pregnancy, especially at 8-12 weeks. In contrast, some already cited data support a reduced risk of preterm birth with vigorous recreational activity, particularly with increased frequency of recreational type activity . In a laet al. [In a retrospective study, Bungum et al.  found thet al. .The results of a meta-analysis of observational studies suggested an inverted U-shaped association between physical activity and birth weight . In otheThere are undoubtedly many advantages of exercise during pregnancy and therefore, after excluding medical and pregnancy-related risk factors, obstetricians should strongly recommend to their patients to be physically active. Non-extreme physical activity prior to and during pregnancy is not only safe for fetal health but is also associated with numerous maternal health benefits, including prevention and better control of gestational diabetes, excessive weight gain, and increased blood pressure. It is worth mentioning that exercise also reduces lower back pain and has positive effects on both maternal mental health and quality of life.The recent recommendations from the American College of Obstetricians and Gynecologists clearly embrace the research cited above. They can be summarized as follows :physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements;a thorough clinical evaluation is necessary before recommending an exercise program to ensure that a patient does not have medical reasons to avoid exercise;women with uncomplicated pregnancies should be encouraged to engage in both aerobic and strength-conditioning exercises before, during, and after pregnancy;obstetrician–gynecologists and other obstetric care providers should carefully evaluate women with medical or obstetric complications before making recommendations on their physical activity participation during pregnancy;regular physical activity during pregnancy improves or maintains physical fitness, helps with weight management, reduces the risk of gestational diabetes in obese women, and enhances psychological well-being.This statement testifies to a tremendous shift in both medical thinking and practical approach from the necessarily conservative position of early guidelines because of lack of research decades ago to the current active encouragement of pregnant women to do mild and moderate exercise as a physiological means to maintain a healthy, or healthier, pregnancy. What a spectacular change we are witnessing!


Newborns in intensive care are regularly exposed to minor painful procedures at developmental time points when noxious stimulation would be normally absent. Pain from these interventions is inconsistently treated and often exists concurrently with systemic infection, a common comorbidity of prematurity. Our understanding of the independent and combined effects of early painful experiences and infection on pain response is incomplete. The main goals of this research therefore were to understand how pain and infection experienced early in life influence future nociceptive and affective responses to painful stimuli. Rat pups were infected with E-coli on postnatal day 2 (PN2) and had left hind paw injury with carrageenan on PN3. Standard thermal tests for acute pain, formalin tests for inflammatory pain, and conditioned place aversion testing were performed at different ages to assess the nociceptive and affective components of the pain response. Early E-coli infection and early inflammatory injury with carrageenan both independently increased pain scores following hind paw reinjury with formalin on PN8, with effects persisting into adulthood in the carrageenan exposed group. When experienced concurrently, early E-coli infection and carrageenan exposure also increased conditioned aversion to pain in adults. Effect of sex was significant only in formalin testing, with males showing higher pain scores in infancy and females showing higher pain scores as adults. These findings demonstrate that infection experienced early in life can alter both the nociceptive and affective components of the pain response and that there is a cumulative effect of local and systemic pro-inflammatory processes on the aversive component of pain. Multiple epidemiological studies worldwide have shown that infants in NICU settings experience an average of 12 painful procedures each day, with the majority occurring in infants <30 weeks gestational age . These pThe International Association for the Study of Pain defines pain as, “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” . A complPrematurity is associated with many comorbidities that adversely affect development and increase the need for invasive procedures, making establishment of causal relationships between early painful experiences and long-term behavioral effects challenging. Systemic E-coli infection is one common complication of prematurity that can lead to critical illness and increased need for painful interventions . A numbeboth early painful experiences and early infection, it is critical to understand the combined effects of these experiences on behavior and development as they may differ from the effects of each alone. The main goals of this research were to understand how infection and pain experienced early in life alter future nociceptive and affective responses to subsequent painful experiences. We hypothesized that exposure to painful stimulation or infection early in life would be associated with heightened nociceptive and affective responses to subsequent painful stimuli experienced throughout development. Specifically, we hypothesized that early systemic infection with E-coli (PN2) or early inflammatory tissue injury with carrageenan (PN3) would each independently produce few changes or a mild hypoalgesia in baseline thermal sensitivity, produce hyperalgesia in the inflammatory formalin test, and produce increased aversion in a conditioned place aversion test on PN8, PN15, or in adulthood. We further hypothesized that concurrent experience of inflammatory pain and systemic infection in early postnatal life would produce heightened hyperalgesia after a later inflammatory injury with formalin and heightened aversion to painful stimulation over and above that seen with either insult alone. Both male and female animals were used to test if hypothesized effects were sex dependent.As newborns in intensive care settings are commonly and concurrently exposed to Although there is published research on the long-term effects of infant pain in both humans and animal models . E-coli4.2Long term effects on basal pain sensitivity following early painful injury are mixed . Lidow aExposure to noxious stimulation in the newborn period has been associated with long-term hyperalgesia after repeat injury , 1997. OIn addition to skin breaking procedures, systemic infections are a recognized complication of being born too soon . Several4.3The affective component of pain Is equally important to the nociceptive component, yet seldom studied. “Suffering”, classically associated with pain, is largely due to how painful experiences make us feel. This goes beyond spinal level reflexes and nociception to involve higher order processing in the brain. In our experiments, we used a classical conditioning paradigm to study learned aversion to painful stimuli. Aversion to pain developed over time, with animals at PN8 still showing a relative preference for the chamber associated with a painful stimulus, as might be expected at this age. This paradoxical finding has been previously demonstrated in animal models of abusive caregivers  where al4.4Determining changes in neural processing due to the combination of pain and infection was beyond the goals of this study but there are several possible mechanisms that can be hypothesized. Among the possible neural changes that could account for our findings, the PAG, spinal cord, and cerebral cortex, have been shown to be altered by pain and infection [in humans: ; in animPain affect is regulated by overlapping and independent brain circuitry. One such circuit is the spinal cord dorsal horn to the parabrachial nucleus to the central and basolateral amygdala, with output to the PAG and communication with the anterior cingulate cortex to modulate pain . Early i5There are several limitations to this work. First, we used a single injury to the paw at a single age. In the NICU, skin breaking events occur multiple times during a day and over the course of days to months. Whether a more intense stimulus such as repeated paw stabs  would haWe tested only baseline thermal nociception for the acute pain test and there were no effects of early treatment. Other tests, mechanical, cold, visceral might be more sensitive to early injury and infection. Additionally, we used the CPA test as a measure of pain affect. One potential limitation to this test is that it involves learning. Our test of necessity was a single trial. If our infant manipulations altered learning capabilities, that might have reduced the effectiveness of the CPA test. Other measures, such as a grimace test, could provide additional assessments of the negative affect associated with pain.Finally, we did not identify the mechanisms underlying the enduring behavioral changes described above. There are multiple possible ways in which the combination of pain and infection could alter adult behaviors that are not influenced by either alone. These could include different circuits, different activation of similar circuits, and changes in how later immune and inflammatory processes are engaged by adult pain.6Our study demonstrates a robust, reproducible, and long-standing change in pain behavior after neonatal exposure to infection and painful stimulation that has not been previously described. Whereas exposure to carrageenan and systemic infection early in life did not alter acute sensitivity to detection of painful stimuli in pups, each resulted in an increased behavioral response to evoked pain in infancy and development of a long-term aversion to pain in adults. Our findings suggest a compounding effect of pro-inflammatory processes on pain behaviors at developmental stages in pups that correlate with postmenstrual ages encountered in the NICU. Additionally, affected animals go on to have increased aversion to painful stimuli in adulthood, highlighting how early life experiences can alter adult behavior long-term. These findings are particularly important in the context of neonatal intensive care, where painful stimulation in preterm babies is common and often occurring concurrently with systemic infection.The next logical step is to identify the mechanisms underlying these long-term changes in behavior. With the behavioral effects well-characterized, follow-up studies can focus on uncovering those mechanisms. Possible studies include defining long lasting changes in CORT release, characterizing altered activity in structures implicated in the long-term effects of either infection or early pain , or assessing how exposure to early pain/early infection changes neuronal firing under both resting conditions and following injury. Use of alternative models of infection  would provide clues as to how generalizable behavioral effects observed following other modes of immune system activation are to our findings with E-coli. Finally, inclusion of other clinical variables, such as treatments for pain, infection or both, into this model would be important to mimic the clinical setting.The authors have no conflicts of interest to disclose.


Prior studies have shown that virtual reality (VR) is an efficacious treatment modality for opioid-sparing pain management. However, the majority of these studies were conducted among primarily White, relatively advantaged populations and in well-resourced settings.We conducted a qualitative, theory-informed implementation science study to assess the readiness for VR in safety-net settings.Using the theoretical lens of the Consolidated Framework for Implementation Research (CFIR) framework, we conducted semistructured interviews with current VR users and nonusers based in safety-net health systems (n=15). We investigated barriers and facilitators to a commercially available, previously validated VR technology platform AppliedVR . We used deductive qualitative analysis using the overarching domains of the CFIR framework and performed open, inductive coding to identify specific themes within each domain.Interviewees deemed the VR intervention to be useful, scalable, and an appealing alternative to existing pain management approaches. Both users and nonusers identified a lack of reimbursement for VR as a significant challenge for adoption. Current users cited positive patient feedback, but safety-net stakeholders voiced concern that existing VR content may not be relevant or appealing to diverse patients. All respondents acknowledged the challenge of integrating and maintaining VR in current pain management workflows across a range of clinical settings, and this adoption challenge was particularly acute, given resource and staffing constraints in safety-net settings.VR for pain management holds interest for frontline pain management clinicians and leadership in safety-net health settings but will require significant tailoring and adaption to address the needs of diverse populations. Integration into complex workflows for pain management is a significant barrier to adoption, and participants cited structural cost and reimbursement concerns as impediments to initial implementation and scaling of VR use. Immersive virtual reality (VR) has emerged as an efficacious treatment modality for a wide range of medical and neurocognitive conditions including pain. VR is delivered via a headset that displays computer-generated and oftentimes interactive audio and visual content that can be designed to reduce pain through techniques such as distraction, relaxation, and mindfulness. Randomized controlled trials and effectiveness studies demonstrate that VR improves pain scores among inpatients and during medical procedures -4. AdditClinicians have demonstrated interest in VR therapy as a safe and effective adjunctive or replacement to opioid agents to avoid adverse consequences of opioid use . Opioid Despite studies proving the efficacy of and great promise for VR therapy as a nonpharmacologic approach to pain management, VR has not become part of routine chronic pain management ,13,14. AThere are specific considerations in adapting digital innovations to diverse populations and to safety-net health care settings that disproportionately care for them . A systeThis study aims to determine barriers and facilitators to the implementation of VR as a treatment for pain in safety-net settings. We obtained institutional review board approval (#19-29025) for this project from the University of California, San Francisco (UCSF) Human Research Protection Program.We developed an interview guide based on the Consolidated Framework for Implementation Research (CFIR) ,21. We cWe used the snowball method of sampling to conduct 15 semistructured interviews  of 5 heaWe used the qualitative software Dedoose  for analysis. Two authors, KN and JL, read all the transcripts in detail. For deductive coding, they assigned excerpts to 1 of the 5 overarching CFIR domains  and met to discuss codes and resolve inconsistencies . They thThe qualitative data generated and analyzed during the current study are not publicly available due to the risk of re-identification of participants, but codebooks are available upon reasonable request.We interviewed 15 participants from a variety of roles and organizations .We defined “user” as a health care provider or staff member interviewee with previous research experience implementing the AppliedVR platform for pain treatment at their delivery system; we defined “nonuser” as a health care provider or staff member interviewee without experience with AppliedVR or other VR platforms for clinical pain treatment.Underlying these results was a strong sense of an unmet need for chronic pain management among users and nonusers. There was agreement among all interviewees that addressing pain management differently represents a high organizational/clinical priority. Building on that universally acknowledged need and prioritization, both users and nonusers of VR identified a range of factors related to the intervention itself and to the milieu in which it would be implemented that they expected would impact VR implementation. We described the major themes within each CFIR domain and provided exemplar quotes.The VR intervention itself has attributes that both facilitate and inhibit implementation , many of the themes that emerged are relevant across multiple innovative approaches to clinical care. The spread of innovations to safety-net health settings requires attention to patients’ language and culture. Efforts to address resource constraints, such as providing staff training and detailed protocols encompassing workflow integration, can lower barriers to innovation. Inclusion of diverse populations and the health care settings where they disproportionately receive care will address issues that are relevant across other health systems as well.This study contributes to the literature by revealing barriers and facilitators to implementing VR for pain management in safety-net settings. We demonstrate that frontline pain management clinicians and leaderships are interested in VR, but it will require significant tailoring and adaptation to address the specific needs of the diverse populations they serve. The participants cited integration into complex workflows, structural costs, and reimbursement concerns as major barriers to implementing and scaling VR use. Future studies should augment this approach with direct observation, quantitative measures of VR use, and direct usability assessment of the AppliedVR platform with diverse patient populations.


Cefepime is a common antibiotic used to treat various infections such as pneumonia, skin infections, and intra-abdominal infections due to its broad gram-positive and gram-negative spectrum. However, patients with acute kidney injury, end-stage renal disease, and renal transplantation are disproportionately at higher risk of developing complications from administration of cefepime, secondary to its predominant renal excretion. Current guidelines prescribe cefepime renal-dosing, dependent on the glomerular filtration rate, to prevent toxicity. This study presents a rare case where an acutely hospitalized patient undergoing chronic renal transplant rejection was administered renal-dose cefepime. Despite renal dosing, the patient developed neurotoxicity that manifested as delirium, inability to tolerate oral intake, and non-convulsive status epilepticus. Solely adjusting for renal dysfunction may be inadequate to prevent the accumulation of cefepime metabolites, which may present in an atypical manner in the patient. Such possibilities emphasize the need for continued evaluation of a patient’s mentation in case of cefepime administration. Cefepime-induced neurotoxicity incidences need to be evaluated and researched thoroughly. Cefepime is a fourth-generation cephalosporin, which is excreted primarily by the kidneys. Cefepime-induced neurotoxicity is a well-documented adverse effect in patients with renal failure. Symptoms are correlated with decreased cefepime clearance due to reduced glomerular filtration rate (GFR) as well as increased central nervous system (CNS) penetration due to blood-brain barrier dysfunction . The symA 64-year‐old caucasian woman with a past medical history of scleroderma with pulmonary fibrosis, renal transplant 18 years ago, chronic pericardial effusion, and hypertension presented to the hospital with two days of right-sided neck pain and stiffness associated with numbness and tingling of her hands. Preliminary work-up was remarkable for an acute kidney injury with severe electrolyte derangements including hypocalcemia, hypomagnesemia, and hyponatremia. After two days of aggressive electrolyte repletion, the patient’s symptoms resolved, but kidney function continued to slowly deteriorate. The regional transplant center was contacted in coordination with the hospital nephrology team who deemed this as an acute chronic renal transplant rejection. Pseudomonas aeroginosa. A ten-day course of cefepime was started for the concurrent infection with consideration of hemodialysis being initiated in the setting of continued worsening renal function. The infectious disease team was consulted for further recommendations given the patient's immunocompromised state and de-escalation of antibiotics with cultures being pan-sensitive. The patient began to develop progressively worsening urinary retention requiring repeated straight catheters and eventually a foley. During this time she began to develop diffuse abdominal pain prompting an infectious work-up and resulting in two blood cultures and urine culture being positive for On day six of cefepime administration, the patient developed acute delirium after undergoing placement of a tunneled dialysis catheter. Initially, the delirium was attributed to side effects of sedation, but the delirium began to worsen. She was interestingly always able to answer the standard orientation questions and partake in a linear conversation but developed fluctuating mental status. This was emphasized by her husband who endorsed unusual conversations with his wife and was further evident by inappropriate effects including hysterical laughter. Infectious work-up and computed tomography of the head were unrevealing. In light of the worsening mental status and progressively decreasing oral intake, an electroencephalogram (EEG) was ordered to further assess the altered mental status Figure . EEG was remarkable for subclinical status epilepticus. The patient was loaded with levetiracetam and put on maintenance dosing for the remainder of the admission. Cefepime was discontinued and meropenem was started under infectious disease recommendations due to reported rare side effects of altered mental status from cefepime. Over the course of the next three days, the patient's mental status, oral intake, and hemodynamic stability improved remarkably. At her outpatient primary care physician appointment two weeks later she was reported to be doing well and had no associated complaints or confusion.Cefepime, a common fourth-generation cephalosporin, has been reported in the literature due to its ability to cause neurotoxicity particularly in patients with renal failure. While the mechanism of cefepime-induced neurotoxicity (CIN) is still being researched, it has been hypothesized in the literature to be related to a decrease in GABA release from nerve terminals through a mechanism that is not fully understood, resulting in hyperexcitation of the neurons and depolarization of the postsynaptic membrane . This maIt was first reported in the literature in 1999 in a patient with end-stage renal disease who was found to have high cefepime levels and subsequently developed altered mental status, myoclonus, and generalized tonic-clonic seizures . CefepimSymptoms of CIN, including encephalopathy, seizures, and EEG changes, generally begin to appear approximately four days after initiation of the antibiotic. Encephalopathy generally manifests as tremor, aphasia, myoclonus, drowsiness, stupor, coma, confusion, delirium, and agitation. In a minority of cases (approximately 13%), a seizure was the only isolated symptom . Diagnosis of CIN is made based on neurological symptoms starting days after cefepime initiation, related EEG findings consistent with generalized periodic discharges with a triphasic wave pattern, and resolution of symptoms and EEG abnormalities following discontinuation of the medication. Furthermore, CIN is a diagnosis of exclusion, and other causes of toxic and metabolic encephalopathy must be ruled out prior to making the diagnosis . Treatment of CIN involves discontinuation of the drug. In a minority of cases with severe presentations, hemodialysis has been initiated for rapid removal of the drug . AntiepiPseudomonas bacteremia secondary to a urinary tract infection. CIN developed approximately six days following the initiation of cefepime, manifested by encephalopathy and EEG abnormalities consistent with subclinical status epilepticus. Other organic causes including metabolic etiologies and stroke were ruled out. Three days after discontinuation of cefepime, the patient demonstrated an increase in oral intake and returned to her baseline mental status.Our case presents a patient with acute renal failure requiring hemodialysis treated with renally-dosed cefepime for coverage of her This case adds to the compilation of literature surrounding CIN due to its unique presentation of encephalopathy and EEG abnormalities in a patient with acute renal failure who received appropriate renally-dosed cefepime. Previous literature surrounding CIN focused on inappropriate renal dosing of cefepime as the major risk factor for neurotoxicity. In our patient, Cefepime was reduced by 50-75% the recommended dose in accordance with her decreased creatinine clearance. Nonetheless, the patient developed signs and symptoms of CIN within the expected time frame, which resolved appropriately with discontinuation of the antibiotic. We theorize that CIN may have developed in our patient despite appropriate dosing due to both her older age and disruption of the blood-brain barrier due to uremia and sepsis.While the majority of cases regarding CIN have focused on inappropriate dosing of cefepime as the major risk factor, this case demonstrates that cefepime-induced neurotoxicity can occur in instances where cefepime is appropriately renally-dosed. It is important to understand this risk when initiating cefepime in an individual with renal failure, and have a low threshold for discontinuation of the medication if the patient begins to demonstrate signs or symptoms of CIN. Future research surrounding the incidence and severity of renally dosed cefepime precipitating CIN is warranted given the increasing use of the antibiotic for the treatment of sepsis.Recognizing cefepime induced neurotoxicity can be a challenging due to a multitude of factors that more commonly are associated with encephalopathy and seizures. However, in the absence of other discernable sources, cefepime-induced toxicity should be considered as a diagnosis of exclusion. Dose adjustment can reduce the incidence of toxicity, but without close monitoring even therapeutic levels can lead to neurotoxicity. While this is one independent case at our institution, further research is needed to identify risk factors other than poor renal function to help recognize the true incidence and assist clinicians in their management.


Smoking rates are significantly higher among young people experiencing homelessness than in the general population. Despite a willingness to quit, homeless youth have little success in doing so on their own, and existing cessation resources tailored to this population are lacking. Homeless youth generally enjoy the camaraderie and peer support that group-based programs offer, but continuous in-person support during a quit attempt can be prohibitively expensive.This study aimed to assess the feasibility and acceptability of an automated text messaging intervention (TMI) as an adjunct to group-based cessation counseling and provision of nicotine patches to help homeless youth quit smoking. This paper outlines the lessons learned from the implementation of the TMI intervention.Homeless youth smokers aged 18 to 25 years who were interested in quitting (n=77) were recruited from drop-in centers serving homeless youth in the Los Angeles area. In this pilot randomized controlled trial, all participants received a group-based cessation counseling session and nicotine patches, with 52% (40/77) randomly assigned to receive 6 weeks of text messages to provide additional support for their quit attempt. Participants received text messages on their own phone rather than receiving a study-issued phone for the TMI. We analyzed baseline and follow-up survey data as well as back-end data from the messaging platform to gauge the acceptability and feasibility of the TMI among the 40 participants who received it.Participants had widespread (smart)phone ownership—16.4% (36/219) were ineligible for study participation because they did not have a phone that could receive text messages. Participants experienced interruptions in their phone use  but reported being able to receive the majority of messages. These survey results were corroborated by back-end data (from the program used to administer the TMI) showing a message delivery rate of about 95%. Participant feedback points to the importance of carefully crafting text messages, which led to high  approval of most text messaging components of the intervention. Qualitative feedback indicated that participants enjoyed the group counseling session that preceded the TMI and suggested including more such group elements into the intervention.The TMI was well accepted and feasible to support smoking cessation among homeless youth. Given high rates of smartphone ownership, the next generation of phone-based smoking cessation interventions for this population should consider using approaches beyond text messages and focus on finding ways to develop effective approaches to include group interaction using remote implementation. Given overall resource constraints and in particular the exigencies of the currently ongoing COVID-19 epidemic, phone-based interventions are a promising approach to support homeless youth, a population urgently in need of effective smoking cessation interventions.ClinicalTrials.gov NCT03874585; https://clinicaltrials.gov/ct2/show/NCT03874585RR2-10.1186/s13722-020-00187-6 National data indicate that 19% of people aged 18 to 25 years in the United States are current (past 30 day) cigarette smokers . They alThis paper is based on our previous research that focused specifically on young homeless smokers and supported the need for cessation programs adapted to this population. We found high willingness to quit smoking among this population but little success in doing so on their own or when using existing available cessation resources ,8-10. InWe also found that homeless youth who are interested in quitting enjoy the camaraderie and peer support that group-based programs offer . TherefoIn this paper, we report on our experiences implementing the first TMI targeted at smoking cessation among homeless youth as a part of a pilot evaluation that found promising results of the TMI on smoking reduction. We lay out the lessons learned in designing appropriate and effective text messages and implementing the technical aspects of the intervention and report on the feedback from the participants regarding different aspects of the intervention. We conclude with a discussion of what worked well and what could benefit from improvement with the hope that our lessons can be of value to other, much-needed TMIs for this particularly vulnerable population.The findings reported here are from a pilot study of 77 current smokers aged 18 to 25 years who desired to quit and were recruited from 3 drop-in centers serving homeless youth in the Los Angeles area. The unit of analysis was the individual, but individuals were assigned to groups  based on the drop-in center where they were seeking services during recruitment hours. The intervention was carried out in a cluster cross-over randomized controlled design such that each drop-in center alternated between serving as an intervention or control site by phase across the field period. After formative work with 26 participants  and nicoThe project team generated 174 text messages to send to all TMI participants , all participants received a follow-up survey that asked for information similar to that at baseline; those in the TMI condition were asked additional questions on their experience with the TMI. The baseline survey was administered in a group setting immediately prior to the group counseling session. We used self-administered paper-pencil forms, which was the most feasible option in our field setting. The follow-up surveys were administered either in person or via phone interview. Survey response forms were then scanned and checked for accuracy. While staff were available to assist participants in completing the surveys, no one required such assistance. Participants received $20 for the baseline survey and $40 for the follow-up survey. The baseline survey had 77 participants while the follow-up survey had 66 participants due to attrition.In As can be seen in Despite the frequent occurrence of phone loss and switching of numbers, 81% (29/36) of TMI participants reported not having problems receiving the texts. Further, 72% (26/36) had no trouble accessing the hyperlinks provided in some of the text messages, allowing them to access supplemental information see . MoreoveIn this paper, we discussed the development of a smoking cessation TMI for young homeless smokers and reported lessons learned regarding intervention components such as development of the messages, (smart)phone ownership, technical challenges with the intervention, and feasibility (such as whether messages were received) and acceptability .Regarding message development, we found that conducting focus groups with young homeless smokers and pilot testing with participants before rolling out the intervention were crucial steps to successfully tailoring the content, tone, and frequency of messages to the target population. Participants preferred messages that provided information specific to their current living situation, were light in tone rather than being preachy, and contained fun elements such as emojis and memes. We then programmed the messages developed with the participants’ input using a web-based text messaging platform that allowed for automatized sending of messages and categorization of participant responses for subsequent sending of appropriate follow-up messages, which minimized human resources required for implementation and guaranteed that messages were sent out with a high success rate.As would be expected based on other research showing widespread cell phone ownership among individuals experiencing homelessness -30, we fLast, similar to prior research finding high acceptability among young people experiencing homelessness for using text messaging for daily data collection , we founOur study has significant strengths such as being the first TMI for smoking cessation support for homeless youth and implementation at 3 sites in the Los Angeles area, which allowed for testing in different contexts. However, it also had limitations. For example, results may not generalize to homeless youth in other geographic areas or to those younger than age 18 years. Due to the study being a pilot, we were intentionally not powered to evaluate statistical differences between the standard and TMI conditions. Future studies should test the promising results of this pilot in a fully powered trial ideally in several different locations to test for generalizability of our results. In addition, it is a limitation that we did not collect qualitative data  with the homeless youth who used the TMI at the end of the study, which might have identified additional strengths and weaknesses of this approach that could inform future research efforts in this area. Clearly, our study contributes to a growing evidence base that TMIs for smoking cessation can be effectively implemented even for highly transient and resource-constrained populations such as homeless youth, but that adaptation to their specific needs (including conducting appropriate formative work) is needed to render the TMI acceptable.In terms of future directions, one specific recommendation we got from participant feedback is that they really enjoyed the group cessation counseling session prior to receiving the TMI and wanted more group elements incorporated into the intervention. Going forward, future smoking cessation interventions for this population should consider using approaches making full use of smartphone capabilities, including virtual approaches to leverage group interaction not requiring in-person meetings such as using social media chatrooms. Given their low costs and low requirements for human resources (particularly given the currently ongoing COVID-19 epidemic), (smart)phone-based interventions are a promising approach to support homeless youth, a population urgently in need of effective smoking cessation interventions.In conclusion, we find that most young homeless smokers have cell phones that allow mHealth interventions, with many being in possession of smartphones that typically have unlimited minutes and texts. Given that almost half also have unlimited data plans, it seems that in the near future internet-based interventions requiring smartphones will also be feasible in this population. In line with widespread concern in the literature, we find that homeless youth reported frequent occurrence of phone loss and switching of numbers. However, despite these difficulties the majority of participants reported not having problems receiving the study texts, and engagement with the different intervention components was generally high. We hope that the lessons derived from this pilot intervention serve as useful inputs for future mHealth studies for this population in need of smoking cessation interventions.


Women’s nutritional status during pregnancy can have long-term effects on children’s brains and cognitive development. Folate and choline are methyl-donor nutrients and are important for closure of the neural tube during fetal development. They have also been associated with brain and cognitive development in children. Animal studies have observed that prenatal folate and choline supplementation is associated with better cognitive outcomes in offspring and that these nutrients may have interactive effects on brain development. Although some human studies have reported associations between maternal folate and choline levels and child cognitive outcomes, results are not consistent, and no human studies have investigated the potential interactive effects of folate and choline. This lack of consistency could be due to differences in the methods used to assess folate and choline levels, the gestational trimester at which they were measured, and lack of consideration of potential confounding variables. This narrative review discusses and critically reviews current research examining the associations between maternal levels of folate and choline during pregnancy and brain and cognitive development in children. Directions for future research that will increase our understanding of the effects of these nutrients on children’s neurodevelopment are discussed. A mother’s nutritional status, as defined by the intake and utilization of nutrients during pregnancy has a significant effect on the development of the fetal brain and subsequent cognitive outcomes later in life . To suppCognition refers to the mental processes involved in the acquisition, retention, and use of knowledge, and the foundational aspects of cognitive development include attention, processing speed, representational competence , and memory ,14. NutrTwo nutrients in particular, folate and choline, have been linked to the prevention of neural tube defects and to both health and cognitive outcomes in children ,24,25,26Folate, or vitamin B-9, is a water-soluble vitamin complex that is an essential nutrient . It cannCompared to folate requirements of non-pregnant women, it is recommended that pregnant women consume at least 400 to 800 μg of folate per day to ensure healthy maternal, placental, and fetal tissue growth ,35,36,37Given the ethical considerations regarding maternal nutrition during pregnancy, experimental research examining the effects of maternal folate deficiency on fetal brain development has been conducted in animals only. Craciunescu et al. found that maternal folate intake affected fetal forebrain progenitor cells during late gestation ,48. In tCholine is also an essential nutrient but was only officially recognized as such in 1998 . There aIt is recommended that choline intake should increase from 425 mg/day in non-pregnant women to 450 mg/day in pregnant women . Large aIn human diets, the most common dietary form of choline is phosphatidylcholine (PC); however, it can also be found as free choline, phosphocholine, sphingomyelin, glycerophosphocholine, and lysophosphatidylcholine . CholineLike experimental studies examining the effects of folate deficiency on brain development in mice, animal models have also shown that gestational choline levels have significant effects on fetal brain development. Studies have found that maternal choline deficiency resulted in decreased progenitor cell proliferation and neurogenesis, and increased apoptosis in the fetal hippocampus ,62,63. FFew studies have examined the interactive effects of folate and choline on fetal brain development. Craciunescu et al. found choline supplementation may modify the effects that dietary folate availability has on neural progenitor cells in the fetal forebrain during late gestation . SpecifiAnimal studies see  suggest Human studies see  have alsIn addition to the above supplementation studies, other studies have used food frequency questionnaires (FFQs) to estimate levels of maternal prenatal folic acid and examine associations with cognitive outcomes. For example, Villamor et al. found that for each 600 μg per day increase in total folate intake during the first trimester of pregnancy assessed using FFQs there was a 1.6-point increase in scores on the Peabody Picture Vocabulary Test, Third Edition (PPVT-III) in three-year-old children . The womStudies have also measured maternal folate concentrations  folate) directly from blood samples collected during pregnancy. Although plasma/serum and RBC folate concentrations are both associated with folic acid intake ,21, theyIn rat and mice models see , high maEnhanced cognitive function associated with increased maternal intake of choline during gestation has also been noted in human studies see . The metAnimal studies have established that gestational availability of folate and choline influences numerous processes that are critical for healthy development of the fetal brain. The current literature also suggests that maternal folate and choline levels during pregnancy may be important predictors of children’s cognitive outcomes; however, there are inconsistencies in the findings that have yet to be resolved. These inconsistencies may be a result of several methodological constraints and confounding factors that have not been accounted for in the current literature.One such methodological constraint is that the methods used to assess folate and choline levels in the current literature are not consistent across studies and some have inherent limitations that limit validity of the findings. For example, several studies have simply assessed whether women did or did not take folic acid or choline supplements during pregnancy and did not account for dietary sources of folate or choline ,72,74,99Another potential methodological constraint is that the gestational trimester in which folate and choline levels are measured could be differentially associated with children’s cognitive outcomes . ChangesAnother issue of concern is that the research to date has examined a limited number of potential confounders. Demographic factors such as family socioeconomic status and maternal and paternal level of educational attainment have been associated with maternal nutrient use and children’s cognitive development ,104. SamIn addition to the already identified methodological and analytical issues, it is important to note that there is an imbalance in the number of studies that considered the effects of maternal folate compared to maternal choline. More human studies have examined the association between maternal folate levels and children’s cognitive outcomes and no studies have investigated their interactive effects. The evidence from animal models suggesting that gestational choline supplementation may reduce the adverse effects of folate deficiency on fetal brain development, supports the conduct of human studies that investigate how these two nutrients interact to influence cognitive outcomes in children.Further, limited research has investigated possible biological mechanisms  that may underlie these associations. It has been noted that folate and choline likely play similar roles in the development of the fetal brain and central nervous system and that their interaction may influence fetal brain development ,48. HoweOne last point that needs to be considered in future research is the level of supplementation. Several studies have reported that supplementing with large amounts of folate or choline during pregnancy may result in adverse child health outcomes, including low birth weight and increased risk for developing autism spectrum disorder (ASD) or colitis ,120,121.In summary, the findings from this narrative review suggest that future nutritional research examining the associations between maternal folate and choline levels and children’s cognitive outcomes should develop and use consistent and accurate methods to measure women’s folate and choline levels across the different trimesters of pregnancy and consider a wider range of potential confounding variables  in order to reduce inconsistencies in results that could be attributable to discrepancies in methodology. Additionally, future research is needed that addresses the following issues: (a) What are the optimal intake levels/status of folate and choline needed during pregnancy to promote optimal child neurodevelopment? (b) Do the optimal levels/status vary across the different trimesters of pregnancy? and (c) Is there a risk to children’s neurodevelopment if maternal intake/status is above or below the optimal levels? Additionally, potential biological pathways  should be examined to further understand the mechanistic basis for both folate’s and choline’s role in children’s brain and cognitive development and how these nutrients might interact within the context of early development to further support children’s neurodevelopment. It is important that future research address these methodological limitations and mechanistic questions to better understand how maternal folate, choline, and their interaction during pregnancy, influence brain and cognitive development in children.Folate and choline are important methyl-donor nutrients that play critical roles in the development of the fetal brain. Animal studies indicate that gestational folate and/or choline levels are associated with structural and cellular alterations in various brain regions such as the cerebral cortex and hippocampus. The current human literature also suggests that maternal folate and choline concentrations during pregnancy may play a role in children’s cognitive development; however, there are some inconsistencies in published research. To address these inconsistencies, future research needs to use consistent methods to assess women’s folate and choline levels during pregnancy, and consider confounding factors , relative maternal folate and choline concentrations  and the potential synergistic effects that maternal folate and choline levels may have on fetal brain development and in turn children’s cognitive development.


We congratulate the authors for a very good paper on an important topic about what the Pediatric Urologists community still has many unanswered questions.The paper compares neonates 6-18 days) to young children (3-19 months), and conclusions should apply only to these age groups: late diagnosis in older children may present other characteristics  remains to be proved as clinically meaningful, as the differences between the two groups are small. An important secondary result is the confirmation that definitive harming to renal function relates to late diagnosis, even when late diagnosis is defined as diagnosis in the first two years of life. Unfortunately, diagnostic delay of posterior urethral valves remains common in low-medium income countries, relating mainly to inappropriate prenatal care.Bladder dysfunction depends on many variables, so that defining the factors that modulate this problem is difficult in practice. Different patients may show varying degrees of bladder dysfunction depending on the degree of obstruction , polyuria, severity of secondary vesicoureteral reflux , and theThe usage of desmopressin to treat posterior urethral valves patients remains controversial, as polyuria in these patients derives from definitive harm to the distal tubules . PerhapsThe authors suggest performing a first urodynamic study within 6 weeks after closure of the neural tube defect, looking for a subgroup of patients with greater risk due to reduced bladder capacity and compliance and high detrusor leak point pressure. Urodynamic studies in children are challenging and it is of utmost importance to know what to look for.The authors went beyond, analyzing the updated scientific evidence on CIC indications, how to do it, how to train parents and which catheters to use in different scenarios, from diameter to hydrophilic coatings. Pharmacological therapies have also been addressed. A long list of studies are presented showing indications and results with the role of anticholinergics, beta3 agonists, alfa-blockers and botulinum toxin.This is a must-read paper for those dealing with children with neurogenic bladder.