People with serious mental illnesses (SMI) such as schizophrenia and bipolar disorder experience excess mortality driven in large part by high rates of poorly controlled and under-treated cardiovascular risk factors. In the USA, integrated “behavioral health home” models in which specialty mental health organizations coordinate and manage physical health care for people with SMI are designed to improve guideline-concordant cardiovascular care for this group. Such models have been shown to improve cardiovascular care for clients with SMI in randomized clinical trials, but real-world implementation has fallen short. Key implementation barriers include lack of alignment of specialty mental health program culture and physical health care coordination and management for clients with SMI and lack of structured protocols for conducting effective physical health care coordination and management in the specialty mental health program context. This protocol describes a pilot study of an implementation intervention designed to overcome these barriers.This pilot study uses a single-group, pre/post-study design to examine the effects of an adapted Comprehensive Unit Safety Program (CUSP) implementation strategy designed to support behavioral health home programs in conducting effective cardiovascular care coordination and management for clients with SMI. The CUSP strategy, which was originally designed to improve inpatient safety, includes provider training, expert facilitation, and implementation of a five-step quality improvement process. We will examine the acceptability, appropriateness, and feasibility of the implementation strategy and how this strategy influences mental health organization culture; specialty mental health providers’ self-efficacy to conduct evidence-based cardiovascular care coordination and management; and receipt of guideline-concordant care for hypertension, dyslipidemia, and diabetes mellitus among people with SMI.While we apply CUSP to the implementation of evidence-based hypertension, dyslipidemia, and diabetes care, this implementation strategy could be used in the future to support the delivery of other types of evidence-based care, such as smoking cessation treatment, in behavioral health home programs. CUSP is designed to be fully integrated into organizations, sustained indefinitely, and used to continually improve evidence-based practice delivery.NCT04696653. Registered on January 6, 2021ClinicalTrials.gov,  Contributions to the literatureThis pilot study examines an implementation strategy designed to overcome key barriers to integrating physical health care coordination and management in specialty mental health settings.This protocol describes a pilot study examining whether an adapted Comprehensive Unit Safety Program (CUSP) implementation strategy, designed for inpatient safety, can support the implementation of integrated physical health care in specialty mental health organizations.The study described in this protocol is the first to develop and implement an evidence-based practice “bundle” integrating guideline-concordant clinical and cross-cutting cardiovascular risk factor care processes for people with serious mental illness.People with serious mental illnesses (SMIs) such as schizophrenia and bipolar disorder experience 10–20 years of premature mortality relative to the overall population . This exIn the USA, low rates of guideline-concordant care contribute to poor control of cardiovascular disease and its risk factors among individuals with SMI, particularly those insured by Medicaid , 15. TheOver the past decade, integrated care delivery models designed to overcome barriers to care driven by general medical-specialty mental health system fragmentation have become increasingly common in the USA. Prominent examples include primary care-based models, including Collaborative Care and Primary Care Medical Homes (PCMHs) –26, as wHistorically, the lack of insurance reimbursement mechanisms for physical-mental health care coordination has been a major barrier to the implementation of integrated care models , 33. HowWhile financing mechanisms are a necessary component of care integration, reimbursement schemes have proven insufficient, on their own, to improve cardiovascular care quality and health outcomes among people with SMI. “Real-world” behavioral health homes have been associated with improved rates of screening and monitoring of cardiovascular conditions, reductions in somatic acute care use, and improved post-hospitalization follow-up . HoweverIn a pilot study guided by the Translating Evidence into Practice (TRIP) framework , we willThis pilot study is guided by the Translating Evidence into Practice (TRIP) model’s four steps for large-scale knowledge translation Fig.  43]. In. In43]. This pilot study uses a single group pre/post-observational design. All study sites will use the CUSP implementation strategy to support the delivery of the guideline-concordant cardiovascular risk factor care processes included in the evidence bundle.Study sites will include five psychiatric rehabilitation programs implementing behavioral health homes in Maryland. Psychiatric rehabilitation programs are outpatient mental health programs that deliver psychosocial rehabilitation services such as vocational training and mental health case management. To qualify for psychiatric rehabilitation services in Maryland, individuals must be receiving care from a psychiatrist who determines that the client has significant functional impairment as a result of their mental illness.In Maryland, psychiatric rehabilitation programs have historically been responsible for coordinating mental health, substance use, and social services, such as housing, employment, and nutrition support for their clients. In 2013, Maryland used the Affordable Care Act Medicaid Health Home waiver to implement behavioral health homes, adding physical health service coordination to the responsibilities of the psychiatric rehabilitation programs that chose to participate in the waiver program. In practice, this waiver allowed psychiatric rehabilitation programs to bill Medicaid on a per-client, per-month basis for physical health care management and coordination, which are not traditionally reimbursable services. At each site, behavioral health home implementation is led by a nurse care manager, with support from a medical director and consulting primary care physician or nurse practitioner. All psychiatric rehabilitation program clients covered by Medicaid are eligible to join the behavioral health home program. Enrollment is led by the nurse care manager at each site and clients actively consent to join the program. Our team’s prior research found that psychiatric rehabilitation programs work to enroll all eligible clients into their behavioral health home programs.The present study will include five behavioral health home sites. Each site has approximately 30 staff, which includes all personnel—leaders, health home providers, psychiatric rehabilitation providers, and support staff, e.g., cafeteria workers—and up to 200 clients with SMI.Aligning with step 1 of the TRIP model, the study team conducted a comprehensive review of clinical guidelines and scholarly literature to create a “bundle” of evidence-based care processes for hypertension, dyslipidemia, and diabetes mellitus among people with SMI. As these conditions are highly co-morbid among people with SMI and involve cross-cutting care delivery processes, we developed a single bundle for all three conditions; the goal is for study sites to use CUSP to implement the evidence-based practices in the bundle. While clinical care guidelines are largely similar for cardiovascular risk factors in people with versus without SMI, some special considerations for this population  are needed. Further, care delivery processes often need to be tailored for people with SMI due to unique challenges faced by this group such as cognitive deficits and transportation barriers. The bundle includes two overarching components: clinical care processes and care coordination and management processes. The bundle developed by the study team was reviewed by four external clinical experts as well as two behavioral health home teams in Maryland and refined based on feedback. Examples of evidence-based practice bundle content are shown in Table The CUSP implementation strategy was developed by the Johns Hopkins University Armstrong Institute for Patient Safety and Quality (“Armstrong Institute”) as a strategy for improving inpatient safety . CUSP waThe CUSP strategy is designed to foster a team-based quality improvement culture where providers work together to identify a patient-centered problem  and then to address barriers to receipt of evidence-based care for that problem , 45. By CUSP was designed to improve inpatient safety, and the training materials and CUSP tools developed by the Armstrong Institute are oriented toward the inpatient context. The study team therefore adapted CUSP trainings and tools to enhance relevance to the community mental health organization context and to focus on physical health care coordination and management. The five core components of the CUSP model, described above, were not modified; rather, we adapted the training and toolkit materials to align with mental health organization culture, workflow, and resources and mental health provider roles, responsibilities, and skills. All adaptations were tracked using the FRAME model, a framework for delineating adaptations across multiple domains including whether the change was planned/proactive or unplanned/reactive, the type of adaptation, and the goal of the adaptation. Any additional adaptations made during implementation will also be tracked using this model .For example, the original CUSP “Science of Safety training,” which is administered to all organization staff during CUSP rollout, was adapted to become the “Science of Quality Training.” The key concepts covered in the training  were unchanged, but the motivating examples provided were changed from inpatient safety scenarios to examples of community mental health programs implementing physical health integration models. In another example, a core CUSP tool, the “learning from defects” tool—a worksheet that CUSP teams use to systematically identify the causes of and potential solutions to “defects” in care processes or systems that lead to adverse patient safety events—was adapted to become the “learning from challenges tool.” Instead of deconstructing an adverse patient safety event that occurred in the inpatient unit, the adapted tool is designed to help CUSP teams walk through a case in which a specific client did not receive optimal cardiovascular risk factor care, e.g., a case where a health home client with uncontrolled diabetes mellitus has not seen their primary care doctor in over a month.CUSP is implemented by interdisciplinary CUSP teams comprising individuals from within the implementing organization. In this pilot study, sites will be encouraged to form teams that include a psychiatric rehabilitation program leader, a health home medical director, a nurse care manager leading behavioral health home implementation, an individual responsible for health IT and/or data management at the organization, and psychiatric rehabilitation program staff involved in behavioral health home implementation tasks such as driving clients to primary care appointments.CUSP is implemented over three phases: pre-implementation, implementation, and sustainment. During the pre-implementation and implementation phases, sites receive support from an expert facilitator trained by the Armstrong Institute. In this pilot study, the pre-implementation phase will be 1–2 months, the implementation phase will be 12 months, and the sustainment phase will be 3 months at each study site.The pre-implementation phase includes CUSP team training Table  and TRIPStaff Input CUSP tool at an all-hands meeting every 6 months, or more frequently as needed. This CUSP worksheet asks staff to identify the ways in which their role at the organization might influence clients’ cardiovascular care and health  and to identify challenges they see in helping clients prevent and/or manage cardiovascular risk factors. The CUSP team uses this input to inform their efforts to overcome challenges and implement the evidence bundle.In the implementation phase, sites implement the five-step CUSP process with support, through monthly meetings and ad hoc requests for assistance, from the CUSP expert facilitator. CUSP teams and the expert facilitator will work together to conduct the introductory science of quality improvement training for all psychiatric rehabilitation program staff (step 1). To implement a process for collecting input from all psychiatric rehabilitation program staff on barriers to delivery of evidence-based cardiovascular care (step 2), the CUSP team will administer the In the inpatient setting, hospital administrators are often not CUSP team members. Thus, other strategies are used to engage senior leaders (step 3), such as “walk-rounds” where senior administrative leaders walk through the care delivery process with front-line providers to understand systemic issues—which often require facility updates, staffing changes, or additional resources, all of which are the purview of senior leadership—contributing to adverse patient safety events. In contrast to hospitals with large numbers of leaders and staff, psychiatric rehabilitation programs in Maryland typically have about 30 total employees. Thus, psychiatric rehabilitation program directors will directly engage by serving as members of the CUSP team.Learning from Challenges tool referenced previously to review a case in which a client did not receive the guideline-concordant cardiovascular risk factor care processes included in the evidence bundle, identify the challenges that contributed to the suboptimal care, develop solutions to overcome those challenges, and create a plan for beginning to implement those solutions over the coming month. Critically, the goal is not just to address the problem experienced by an individual client but to enhance systems to prevent the issue from happening to all clients in the future. In other words, if client X was hospitalized with uncontrolled diabetes and the CUSP team learns that she missed three primary care appointments in the 2 months prior to the hospitalization, the goal is not only to make sure client X receives needed outpatient care but also to set up a system to make sure all clients with poorly controlled diabetes have regularly scheduled primary care visits and that clients are supported in attending those visits through reminders, transportation, accompaniment to the appointment, etc. Step 5 of CUSP, use CUSP tools to improve teamwork and communication, is ongoing across CUSP phases as noted with the Staff Input and Learning from Challenges tools above , Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM). Each of these measures includes four items measured on a 5-point Likert scale. An average score for each measure is calculated by summing responses across all four items and dividing by the total number of items. A higher score signifies greater acceptability, appropriateness, or feasibility. These survey measures will be completed by all CUSP team members.Measures of client receipt of evidence-based cardiovascular risk factor care will include the percent of eligible consumers who receive each of the following evidence-based care practices: percentage of clients with SMI with poorly controlled hypertension (see definition below) who had a follow-up blood pressure measurement within 3 months; percentage of clients with SMI diagnosed with diabetes mellitus who received each of the following in the past 12 months: a lipid panel, statin therapy, a dilated eye exam, a foot exam, and a urine-protein-creatinine test; percentage of clients with SMI diagnosed with diabetes mellitus who had a HbA1c measurement in the past 6 months; and percentage of clients with SMI diagnosed with dyslipidemia who received a lipid panel in the past 12 months. We will also measure the percentage of clients with SMI diagnosed with each of the three cardiovascular risk factors of interest who received diet and exercise counseling.Measures of cardiovascular risk factor control will include the percentage of clients with SMI diagnosed with hypertension who have controlled hypertension, defined as blood pressure < 130/80 mmHg; percentage of clients with SMI diagnosed with dyslipidemia who have controlled dyslipidemia, defined as low-density lipoprotein total cholesterol < 200 mg/dl and LDL < 130 mg/dl (primary measure) or on a statin (secondary measure); and the percentage of clients with SMI diagnosed with diabetes mellitus with controlled diabetes, defined as HbA1c < 7.0.Fidelity of implementation of CUSP to support the delivery of the cardiovascular risk factor evidence bundle will be measured using the Stages of Implemented Completion (SIC) tool . The SICMeasures of CUSP team members’ perceptions of implementation barriers and facilitators will be coded in the focus group data. Baseline measures will focus on pre-implementation perceptions of barriers and facilitators. Fifteen-month measures will focus on perceptions of barriers and facilitators following the expert-facilitated implementation phase and the 3-month sustainment phase without expert facilitation.We will use survey measures to collect information on psychiatric rehabilitation program providers’ age, gender, race, ethnicity, length of time working at the program, and role in the program. We will use client record abstraction to collect data on clients’ diagnoses of hypertension, dyslipidemia, and diabetes mellitus as well as their mental health and substance use disorder diagnoses; tobacco use; height and weight; medications prescribed; and sociodemographic characteristics including age, gender, race, ethnicity, living arrangement, disability status, and transportation needs.After each focus group, the study team member leading the group will create a summary memo. This summary memo will help to identify preliminary themes within the data. Focus group transcripts will then be analyzed using a staged approach, which begins with general coding and then evolves to include more specific codes. The study team will create an initial codebook based on the research questions and focus group summary memos. Two coders will pilot the codebook using a random sub-sample of transcripts. Additional themes that emerge during the pilot phase will be added to the codebook. Disagreement between the two coders will be resolved through a discussion with the full study team. The finalized codebook will be applied to all focus group transcripts, and qualitative research software will be used to organize text segments according to themes and sub-themes. We will conduct member-checking by asking all focus group participants to provide feedback on a memo summarizing key themes.We will conduct two main analyses. First, we will compare pre/post  quality improvement culture and provider self-efficacy, the mechanisms through which CUSP is designed to improve the delivery of evidence-based care. Second, we will examine the changes in clients’ receipt of evidence-based care for hypertension, dyslipidemia, and diabetes mellitus and cardiovascular risk factor control from baseline to 6 and 12 months after implementing CUSP, controlling for client characteristics. For both analyses, we will use linear mixed effects modeling approaches for continuous outcomes and generalized estimated equations for binary outcomes. The models will include pre/post-CUSP indicators, fixed effects for the five study sites, and provider/client characteristics. We will use an unstructured variance-covariance model allowing different variances at outcome measurements over time. In addition to these main analyses, we will examine CUSP team perceptions of intervention acceptability, appropriateness, and feasibility descriptively at baseline and at 12-month follow-up.For qualitative analyses, two coders will independently code a random sub-sample of transcripts to generate the initial codebook and reconcile disagreements with the full study team. The member-checking described above will also help avoid bias in the study team’s interpretation of the data. For quantitative data, social desirability is a threat to survey measures of quality improvement culture and self-efficacy. To minimize this threat, survey responses will be confidential and reported only in aggregate form, processes that will be noted in the informed consent process. Measurement error is a threat to analyses of client record data given that sites have varying levels of data reporting infrastructure. We work to minimize this threat by having all sites report data in a standard database developed by the study team. This database will be quality-checked throughout the study by research staff.Recent financing mechanisms to support integrated mental-physical healthcare models, such as the Affordable Care Act Medicaid Health Home waiver used to finance the Maryland behavioral health home programs participating in this pilot study, create a critical infrastructure to support the adoption of care integrated models. This pilot study tests the potential for the CUSP implementation strategy, which has been shown to be effective and sustainable in the inpatient safety context, to support evidence-based care coordination and management for hypertension, dyslipidemia, and diabetes mellitus among clients with SMI participating in behavioral health home programs.Qualitative and survey research suggests that poor alignment between specialty mental health program culture, which has historically focused strictly on mental health treatment, and behavioral health homes’ physical-health oriented goals is a threat to successful behavioral health home implementation. The lack of structured protocols for conducting effective physical health care coordination and management is another key implementation barrier; behavioral health homes in Maryland and other states do not currently use this type of standard protocol, resulting in a high degree of variation across sites. Standard protocols have the potential to promote self-efficacy to conduct physical health coordination and management among behavioral health home staff, many of whom do not have prior training or experience in these domains. In the inpatient safety context, the CUSP implementation strategy has been shown to support cultural shifts and implementation of standard processes and systems for the delivery of evidence-based services.While CUSP is an intensive implementation strategy, behavioral health home teams already meet regularly and work together to improve care; the CUSP strategy is designed to help these teams work more efficiently and effectively. Our pilot study is designed to collect in-depth implementation data. Study sites are committed to participation and will be compensated for their time and effort for focus groups and surveys. While CUSP directly targets key cultural and process barriers to physical health care coordination and management in behavioral health home programs, it does not directly address other important barriers including inadequate financing and poorly integrated specialty mental health and general medical health IT systems. The inclusion of organization leadership in CUSP teams is designed to support strategies to overcome these significant system-level barriers, but progress on these dimensions will likely be long-term. Our single group, pre/post-pilot study design does not allow us to make causal inferences about the effects of the CUSP implementation strategy on outcomes. This pilot study is designed to inform the development of a future randomized clinical trial.Team-based care is increasingly used in integrated mental-physical healthcare models across the country, making the CUSP implementation strategy relevant for a wide variety of settings. While we apply CUSP to the implementation of evidence-based hypertension, dyslipidemia, and diabetes care, our evidence bundle can be updated in the future to include other issues such as smoking cessation treatment. CUSP is designed to be fully integrated into organizations, sustained indefinitely, and used to continually improve evidence-based practice delivery.


While significant advances have been achieved with non-living synthetic cells built from the bottom-up, less progress has been made with the fabrication of synthetic tissues built from such cells. Synthetic tissues comprise patterned three-dimensional (3D) collections of communicating compartments. They can include both biological and synthetic parts and may incorporate features that do more than merely mimic nature. 3D-printed materials based on droplet-interface bilayers are the basis of the most advanced synthetic tissues and are being developed for several applications, including the controlled release of therapeutic agents and the repair of damaged organs. Current goals include the ability to manipulate synthetic tissues by remote signaling and the formation of hybrid structures with fabricated or natural living tissues. In this Perspective, synthetic tissues are defined as organized three-dimensional (3D) collections of non-living communicating synthetic compartments or cells. They are built from the bottom-up with biological or synthetic parts, and can, therefore, be inexpensive and easy to handle. While their simple nature may impart a lack of sophistication, it does mean that their properties are predictable. Furthermore, because their constituents can include components not found in natural tissues, there are no rules constraining their fabrication. Given the intriguing potential applications, especially in medicine, research in the area of synthetic tissues is intensifying.Natural tissues comprise collections of cells and are thereby compartmented . The celSynthetic tissues are materials designed to substitute for natural tissues and even exhibit enhanced properties. They generally comprise a 3D-patterned collection of compartments  that can communicate with each other and with the environment. In the present context, synthetic tissues are built from the bottom-up and do not contain living cells. Indeed their design need not be restricted by attempts to strictly mimic nature.Attempts have been made to produce synthetic tissues from collections of lipid vesicles, each bounded by a single bilayer ,5 Figur. In thesSynthetic tissues built from picoliter droplets connected by interface bilayers (DIBs)  Figure  have reaA third class of synthetic tissues might be assembled from synthetic cells comprising coacervate droplets. The investigation of membraneless organelles in living cells is an intriguing area of current research . These oSeveral challenging issues remain in the construction of synthetic tissues. These include the incorporation of functional sub-compartments (organelles), which has been achieved in synthetic cells (e.g. ), and thTo illustrate the functional properties of synthetic tissues, we focus on DIB-based materials with which most advances have been made .2+ ions can be monitored with fluorogenic dyes both between compartments and between compartments and the environment [2+ has not been observed in this way, electrical signals have been sent through larger structures in the form of ionic currents. Rapid directional transmission can be achieved by patterning pathways containing the α-hemolysin pore by 3D printing [Transport between compartments in synthetic tissues has been mediated by using protein pores, notably α-hemolysin , which iironment . While tprinting   must be maintained by an energy source. Ionic gradients  and encain situ by, for example, cell-free protein synthesis. Synthetic tissues that include responsive polymers might produce mechanical responses, such as gripping or useful shape changes or movement. Electrical outputs would include the patterned injection of ions into a biological interface. Simple computational processing whereby a synthetic tissue can integrate two or more incoming signals or choose between two or more outputs, also remains to be developed, although slow versions have been demonstrated in systems containing just a few droplets [An important future goal for researchers on synthetic tissues is the production of more sophisticated signaling systems. Such systems will include receptors for physical and chemical inputs, means to process the signals and transmit them through the tissues, and finally various outputs . Considedroplets .in vivo and their immunogenicity will be of concern.Living cells can also be assembled into patterned 3D structures by various processes ,39,40 inWhile much progress has been made on non-living synthetic cells, less work has gone into the fabrication of synthetic tissuesCommunicating compartments partitioned by DIBs are the basis of the most advanced synthetic tissuesSynthetic tissues can incorporate features that go beyond mimicking natureSynthetic tissues are being developed for several applications including the controlled release of therapeutic agents and the repair of damaged organsCurrent goals include the powering of synthetic tissues with an energy source, the manipulation of synthetic tissues by remote signaling and the establishment of hybrid structures with tissues containing living cells


Saccharomyces cerevisiae. By focusing on and comparing functional genomics and transcriptomics approaches we identify common mechanisms potentially underlying phenolic toxicity. Additionally, we discuss possible ways by which integration of data obtained across multiple unbiased approaches can result in new avenues to develop yeast strains with a significant improvement in tolerance to phenolic fermentation inhibitors.Synthetic biology has played a major role in engineering microbial cell factories to convert plant biomass (lignocellulose) to fuels and bioproducts by fermentation. However, the final product yield is limited by inhibition of microbial growth and fermentation by toxic phenolic compounds generated during lignocellulosic pre-treatment and hydrolysis. Advances in the development of systems biology technologies  have rapidly resulted in large datasets which are necessary to obtain a holistic understanding of complex biological processes underlying phenolic compound toxicity. Here, we review and compare different systems biology tools that have been utilized to identify molecular mechanisms that modulate phenolic compound toxicity in  Biomanufacturing is transforming how new and existing platform chemicals are made in a way that is environmentally friendly, renewable, and sustainable. To make bio-derived chemicals competitive to fossil-derived chemicals, high productivity and cost reduction are a major consideration. Therefore, there has been a growing interest in using cheap and readily available feedstocks, such as plant material (lignocellulose) obtained from agricultural and forestry wastes.Lignocellulose is an abundant and ubiquitous biomass feedstock that can be hydrolyzed to yield simple sugars which are fermented by yeast to produce bioethanol, fine chemicals, and other bioproducts . HoweverPhenolic compounds exist in different forms in lignocellulosic hydrolysates as phenolic acids , phenolic aldehydes , phenolic ketones , and phenolic alcohols. The concentrations of each of these compounds in hydrolysates vary depending on the plant material and the pre-treatment method used. They appear to have different toxic effects on the cell with phenolic aldehydes being the most toxic and completely inhibit yeast growth at concentrations as low as 1 and 5 mM for coniferyl aldehyde and vanillin, respectively . The difApart from converting lignocellulosic materials to bioethanol and other chemicals by fermentation, there has been a recent interest in valorizing lignin in lignocellulose to produce precursors and final products for the fine chemicals industry . VanilliA thorough understanding of the mechanisms that modulate phenolic compound toxicity is required to engineer yeast strains that are tolerant to individual phenolic compounds and/or a complex mix of phenolics found in hydrolysates. As inhibitor tolerance is a multigenic complex trait  global cS. cerevisiae. We also highlight the potential of exploiting proteomics and metabolomics approaches, which remain underutilized in the field. Finally, synthetic biology approaches and future developments that can rapidly be used to generate yeast tolerant to phenolic fermentation inhibitors are discussed.Here, we review several unbiased functional genomics and transcriptomic approaches to identify general and specific genetic targets that modulate phenolic compound toxicity in Improving yeast tolerance to phenolic compounds first requires the identification of genes and pathways that can be engineered to confer increased tolerance. Therefore, functional genomic tools including chemogenomic screens, adaptive laboratory evolution, genome shuffling, and high content imaging can be exploited to discover genes associated with biological processes underlying phenolic tolerance in yeast.BNA7 which was found to enable yeast growth, when deleted, in media containing ferulic acid , chromatin modification and transcription  , ergosterol biosynthesis (ERG2) and oxidative stress response  were among the top hits that came up in the screen   have bee9, HTZ1) . These b9, HTZ1) ; Table 1e screen . Since tYAP1, DAL81, GZF3, LEU3, PUT3, and WAR1 were required by yeast to grow in coniferyl aldehyde  and vesicle trafficking (SSH4 and VAM6) as important for conferring tolerance to a mixture of phenolics in a synthetic hydrolysate  whose deletion resulted in tolerance to poacic acid were identified (The yeast deletion libraries are barcoded with a unique 20 bp sequence placed upstream (uptag) and downstream (dntag) of the KanMX selection marker gene used to replace the gene of interest . Geneticrolysate ; Table 1entified ; Table 1Although chemogenomic screens, serve as a powerful tool for identifying genes associated with phenolic compound tolerance (sensitive mutants), it remains a challenge to identify suppressors by either method. This is likely because in most cases the growth improvement of the suppressors is small at the sub-lethal concentrations these screens have been performed at. However, success at identifying suppressors can be improved by performing parallel chemical genomic screens at multiple dosages. Further, chemogenomic screens are limited in that they only screen the impact of loss of open reading frames, hence this type of screen excludes gain or separation of function mutations and mutations in regulatory regions. Again, current screens have only probed the non-essential genes, and have not probed the essential mutant collections. Plus, chemogenomic screens are not ideal for selecting tolerance phenotypes that are as a result of epistatic interactions between multiple genes since it only determines the effect of single-gene deletions or mutations.SGE1, was found to improve yeast tolerance to a yeast growth inhibitor used as a pre-treatment solvent , selecting for tolerant haploids and mating them to obtain diploid strains . The diprolysate ; Table 1rolysate . As suchrpl8aΔ, rpp1bΔ, and rpl16aΔ) that had the closest resemblance to vanillin-treated cells lacked genes belonging to the gene ontology (GO) term “cytoplasmic protein component of the large ribosomal subunit”, which are components of the mitochondrial electron transport chain, together with an electron donor to the mitochondrial electron transport chain (CYC1), were upregulated in both vanillin-tolerant yeasts. This suggests an induction in aerobic respiration and energy generation in vanillin adapted strains is critical to confer tolerance . Additionally, FAA1, PRS3, and ALD5 were repressed in both vanillin-tolerant and coniferyl aldehyde-tolerant strains under non-stress conditions. The similarity in gene expression profiles in coniferyl aldehyde- and vanillin-adapted yeast from independent studies suggest that yeast utilizes common mechanisms to build tolerance to these compounds. Knowledge of these commonly induced pathways in adapted strains could be exploited to further improve phenolic tolerance.Remarkably, yeast strains evolved for vanillin tolerance in two independent studies displayed a similar transcriptome profile . SubunitYLH47 that was upregulated in ferulic acid, coniferyl aldehyde and isoeugenol-treated cells, no particular set(s) of genes overlapped in all the studies. Though direct comparisons between transcriptomic studies have limitations  during growth share limited common features . In thesitations , these tCIT1, LSC2, SDH1, SDH2) encode enzymes in the TCA cycle. Similarly, genes involved in oxidation-reduction , transport (SNQ2) and response to oxidative stress (SRX1) were upregulated in both coniferyl aldehyde-adapted yeasts (non-stressed conditions)   and in uditions) .Taken together, oxidation-reduction, electron transfer chain, and the TCA cycle are enriched in the transcriptome of yeast during phenolic toxicity suggesting an upregulation of mitochondrial activity during phenolic stress . A broadWhile transcriptomics can identify gene targets that when overexpressed or downregulated can improve phenolic tolerance, this technology is challenged by the fact that changes in the expression of most genes do not correlate with improved tolerance to yeast stress . Hence tThough functional genomics and transcriptomic studies have so far dominated the field of yeast phenolic tolerance, they clearly do not capture all the biological events that occur upon exposure to phenolics. While functional genomics identify proteins and pathways required for survival upon exposure to phenolics, it fails to assess how these proteins are regulated and their biological role in phenolic tolerance. Gene expression modulation during phenolic compound stress serves as a tangible way of quantifying induction and repression of genes associated with phenolic toxicity. However, RNA levels can only be used as a proxy for measuring products of expressed genes within the cell and may not reflect protein levels, protein function or modification of proteins by post-translational modifications. Further, neither functional genomics nor transcriptomics can assess how phenolic exposure modifies a cell’s metabolism. Hence, two emerging systems biology approaches worth highlighting that can provide this extra layer of genome-wide information are proteomics and metabolomics.One approach to capture protein changes in the cells is the shotgun proteomic method which involves digesting total cellular proteins (isolated from cells treated with or without a toxic compound) into peptides which are separated by liquid chromatography followed by identification and quantification using mass spectrometry . Beyond S. cerevisiae that exhibited remarkable tolerance to a synthetic inhibitor cocktail containing ferulic acid, cinnamic acid, and coniferyl aldehyde  resulted in hypersensitivity to phenolics  are upregulated during phenolic exposure as shown in the transcriptomic studies  that play a role in phenolic tolerance  is enriched in yeast exposed to coniferyl aldehyde  have been reported to upregulated upon phenolic exposure in transcriptomic studies , ergosterol biosynthesis  and cell membrane-associated proteins  are upregulated during growth in phenolic compounds  and tolerance are closely connected, making certain genetic manipulations associated with phenolic tolerance may lead to unwanted trade-offs in production hosts which can negatively impact product yield and titers. Therefore, to ensure the success of engineering yeast phenolic tolerance, metabolic flux analysis should be performed to assess the effect of the genetic modifications on the general physiology of the cell as well as carbon flux toward product formation. Such metabolic flux analyses should quantify and guide efficient resource allocation to ensure that cellular resources, such as NADPH and ATP are not diverted to phenolic tolerance at the expense of biosynthesis of bioproducts in the production strain.Lastly, in the context of producing phenolic compounds, such as vanillin by fermentation, metabolic regulation of pathways that result in the catabolism of the phenolic as a detoxification strategy should be eliminated to improve yields.S. cerevisiae. While common themes or mechanisms coincide among multiple studies, the different approaches provide alternative pathways and biological processes that can be exploited for strain improvement. Moving forward, since most of the long list of genetic hits reported in the various studies has not been validated, significant effort is required to confirm their actual role in tolerance or sensitivity to phenolics. This is particularly crucial for the transcriptomics data because the fact that a gene is upregulated or enriched during stress does not necessarily mean an overexpression of that gene will result in tolerance  and a reporting system , and inserted into a library of yeast mutants. Next, by applying microfluidics, a pool of heterogenous yeast mutants can be sorted to isolate phenolic tolerant strains that can be used in fermentation-based biomanufacturing to increase product yield and titers.Finally, establishing the metabolomic profile of EF and KB conceived and designed the study. EF drafted the initial manuscript. KB edited and corrected the manuscript. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Retrobulbar hemorrhage (RBH) is a rare complication of facial trauma that can lead to dangerous orbital compartment pressures and must be rapidly recognized to prevent permanent vision loss. Point-of-care ultrasound (POCUS) offers a rapid modality for evaluating a wide variety of ocular pathologies, and prior case reports demonstrate the ability of clinicians to recognize RBH using ultrasound. This study aimed to assess the ability of clinicians at various stages of training to identify a RBH using POCUS in a cadaveric model. Clinicians also were assessed for self-reported comfort using ultrasound for ocular pathology before and after the study.Participants included 17 physicians who evaluated 10 eyes (from five cadavers) that were independently randomized to have either a modeled RBH or no hemorrhage. Participants’ final diagnosis of each eye was recorded (RBH present or not), and participants also completed pre- and post-activity surveys.The overall sensitivity and specificity to correctly diagnose retrobulbar fluid was 87% and 88%, respectively. Sensitivity and specificity were higher after excluding clinicians in their early phase of training. Additionally, self-reported comfort level with ocular ultrasound was significantly improved by this activity.Emergency physicians at a variety of training levels can correctly identify a cadaveric model of retrobulbar hemorrhage. Use of this cadaveric model can improve exposure of clinicians to the appearance of a rare but vision-threatening ocular pathology such as RBH. Retrobulbar hemorrhage (RBH) is a rare complication of facial trauma; however, it must be rapidly recognized to prevent permanent vision loss from increased orbital compartment pressures.5Cadaver models represent a useful way to simulate rare pathologies for both research and educational purposes.This study was accomplished in the Bioskills laboratory of Northwell Health Systems, using fresh frozen cadavers and in compliance with department policies and institutional review board standards. To prepare the eyes for analysis, 5–10 milliliters (mL) of normal saline was injected into the posterior chamber using a 22-gauge needle to restore the normal anatomic shape (as cadaveric eyes become desiccated). Five cadavers were available for this study, and each eye  was independently randomized to be either normal or have RBH. For the eyes randomized to the RBH group, 10–20 mL of a normal saline and gel mixture (1:1) was instilled posterior to the eye under ultrasound guidance . ParticiEach participant was given a pre-activity survey and a brief instructional introduction on the use of POCUS for ocular pathology and the appearance of RBH on ultrasound. During the introduction, participants were given a 15-minute didactic presentation summarizing techniques for ocular POCUS, representative normal images, and examples of RBH. Each participant had the opportunity to use either a SonoSite M-Turbo ultrasound  equipped with a linear 10 megahertz array, or a Philips Lumify L12-4 linear array  (attached to an Android-based LCD screen) on each cadaveric eye. Participants then recorded the presence or absence of a RBH for each eye. Participants completed a post-activity survey regarding their comfort level with ocular ultrasound and likelihood to use in clinical practice. Following completion of the study, each participant’s surveys and score sheet were given a unique randomized number without additional identifying information.Results of participants’ evaluation of each eye were recorded and analyzed for sensitivity and specificity, and further analyzed by subgroups according to level of training. Additionally, survey responses for all groups were recorded and a comparison was made for each question regarding comfort level and likelihood to use POCUS for evaluation of ocular pathology.In this pilot study, a total of 17 participants evaluated 10 eyes (five cadavers) prepared for this investigation . What do we already know about this issue?Retrobulbar hemorrhage, a rare complication of facial trauma, must be rapidly recognized to prevent permanent vision loss.What was the research question?This study assessed if clinicians could identify a cadaver model of retrobulbar hemorrhage using point-of-care ultrasound.What was the major finding of the study?Emergency physicians could accurately identify the ultrasound findings of a retrobulbar hemorrhage in a cadaver model.How does this improve population health?This model can improve the familiarity of clinicians to the ultrasound findings seen in patients with retrobulbar hemorrhage.The participants were able to distinguish those eyes with a modeled RBH from “normal” anatomy, with an overall sensitivity and specificity of 0.87 and 0.88, respectively . This inThe participants reported their comfort level with using physical exam and POCUS for evaluating ocular pathology before and after the exercise, using a five-point Likert scale. Both saw statistically significant increases in comfort level after completion, based upon an increased, self-reported comfort level.RBH is a rare but potentially devastating injury that must be rapidly recognized to treat effectively; however, concomitant craniofacial injuries can affect an examiner’s ability to recognize signs of RBH on physical exam. Additionally, the time associated with obtaining and reading CT images can lead to dangerous delays in diagnosis. POCUS can be used to rapidly screen for RBH at the patient’s bedside and without the patient having to leave the department for imaging. Previous case reports have documented the use of POCUS to identify RBH; however, the rarity of this pathology has made more systematic research difficult.Our pilot study indicates that human cadaver models can be used to effectively train emergency medicine practitioners to recognize sonographic signs of a RBH. After the completion of a focused training session, the participants successfully identified a RBH on ultrasound with a sensitivity and specificity that increased with the level of postgraduate training. We noted a sensitivity of 0.96 and a specificity of 0.94 with recognizing RBH in those PGY-3 level of training or higher. Physicians currently enrolled in the ultrasound fellowship who participated in this study had a sensitivity and specificity of 100%, suggesting that more advanced training can further increase the diagnostic utility of ocular ultrasound. Attending scores decreased slightly to 0.92 (sensitivity and specificity), likely reflecting higher proficiency among ultrasound fellows with more recent, advanced training.Using our pre- and post-study questionnaires, our study showed a significant increase in participants’ comfort level in using POCUS to diagnose RBH. Physician likelihood to use ocular ultrasound was unchanged from the activity; however, given that the ranking was initially high (4 out of 5), any increase in likelihood-to-use may not be measurable with the low sample size obtained. Based upon these findings, fresh frozen cadavers can provide an accurate educational simulation of RBH on ultrasound.Our study had several limitations. The sample size was small and lacked the ability to test the same number of residents and attendings per PGY level. Although using fresh frozen cadavers provided simulation of true pathology, the lack of eye movement seen in live patients may have allowed for easier detection of RBH. The cadaver models did not represent several other aspects of real-life diagnosis, such as patient discomfort, uncooperative patients, or concomitant traumatic injuries . Additionally, this cadaver model contained other ocular pathology on ultrasound, such as the appearance of retinal detachments (likely resulting from cadaver preparation). This study was also limited to the evaluation of RBH greater than 10 cubic centimeters in volume, and there is likely a decrease in sensitivity and specificity with smaller volumes. Future studies could assess the accuracy of identifying different retrobulbar volumes. Despite these limitations, this approach represents a feasible method for reliably representing a rare pathology for physician education.Emergency physicians can use POCUS to correctly identify a cadaveric model of RBH. Higher levels of training seem to correlate with improved accuracy in diagnosing this condition. Use of this model can improve clinicians’ exposure to the appearance of rare, vision-threatening ocular pathology, such as RBH. More study will be needed to assess the accuracy of POCUS for identifying retrobulbar hemorrhage in live patients.


Thoracic insufficiency Syndrome (TIS) is a recently coined phrase to describe children with spine and chest wall deformities, inherited and acquired, who have respiratory impairment, and are skeletally immature. This population has both restrictive and less often obstructive lung disease due to changes in spine and rib configuration which reduce lung volume, stiffen the chest wall, and reduce respiratory muscle strength. Although the population is heterogeneous with regard to age of onset, etiology, severity of deformity, and rate of progression of the deformity, there are common issues that arise which can be addressed by pediatric pulmonologists. These are illustrated in this review by using Early Onset Scoliosis as a common form of TIS. The pulmonary issues pertaining to TIS require collaboration with multi-disciplinary teams, particularly spine surgeons, in order to make decisions about non-surgical and surgical strategies, timing of surgery and medical supportive care over time. Pulmonary input about respiratory function should be used in conjunction with structural features of each deformity in order to determine the impact of the deformity and the response to various treatment options. In those patients with residual lung function impairment as young adults, pediatric pulmonologists must also ensure successful transition to adult care. Thoracic Insufficiency Syndrome (TIS) is defined as impairment in breathing and/or postnatal lung growth due to spine and thoracic cage deformity in children who are skeletally immature . It is dThis chapter addresses the input that pulmonologists can provide at all ages in children with EOS as an example of TIS, as part of an multi-disciplinary team, which ideally includes spine surgeons, pulmonologists, general surgeons, neurosurgeons, pediatric sleep specialists, nutritionists, genetic counselors, physical therapists, and bioethicists. The management of children with TIS begins on first encounter and ends for many with transition to adult care, i.e., over 15–20 years with multiple surgical procedures throughout that time. Pediatric pulmonologists are ideally involved with management questions that arise throughout this time period.TIS is often recognized in the newborn period by respiratory distress associated with hypoplastic thoraces due to inherited skeletal dysplasias. Small chest walls are classified by surgeons as thoracic “volume depletion” disorders due to the small size of the chest wall. Classic examples are Jeune's syndrome (asphyxiating thoracic dystrophy) and Jarcho-Levin syndrome . Khombourlis has reviewed the more than 100 different skeletal dysplasias that can produce respiratory impairment in infancy . Many ofA common condition producing TIS is early onset scoliosis (EOS) which presents before 10 years of age with a coronal curve spine curve >10 degrees. The coronal degree of spine curvature is measured using the Cobb angle, illustrated in Congenital scoliosis is defined by the presence of vertebral and rib structural deformities such as vertebral hemi-vertebrae and failure of segmentation with fused or block vertebrae. These may be associated with multiple fused ribs which either constrain chest wall motion or provide large gaps between ribs that may produce a flail chest syndrome. Many syndromes, e.g., VACTERL syndrome, have multiple organ involvement and decisions must be made what to treat first. Up to 12% of children with congenital scoliosis also have congenital heart disease, and these children represent an overlap between congenital and syndromic categories  with infantile idiopathic scoliosis and small coronal spine curves (<30 degrees) there is high rate of reversal to an almost normal spine shape with serial casting treatment over a period of years . Children will often avoid large meals and graze, eating frequent small volume snacks. Failure to thrive is reported in 50% of children with EOS and responds in most cases to caloric supplementation either by mouth or with a feeding tube or gastrostomy tube .Obstructive lung disease occurs in 10–30% of children with EOS , 20. In Distortion of the thorax and spine deformity can alter the distribution of ventilation and perfusion quantitated by nuclear lung scans. Unless there is a history of past lung or airway insults, such as pneumonia, the distribution of ventilation and perfusion closely track one another in children with EOS. However, more than half of children with EOS have asymmetric function with one lung functioning better than the other . This caper se are atrophied or adapt to chronic mechanical loads. In animal models of EOS produced early in life, the diaphragms in adulthood have reduced cross-sectional surface area  and Maximum Expiratory pressures (MEP) in children with EOS and correlation with loss of vital capacity  23). Re. Re23). ace area .The reduced MEP is explained in part by the reduced total lung capacity, the lung volume at which MEP is generated. Reduced TLC is the hallmark of restrictive respiratory disease and the further it is reduced, the more MEP is compromised. Of interest, MEPs tend to be reduced to a greater degree than MIPs although both correlate with diminished vital capacity, as illustrated in . Reductiper se  that is <10% of predicted norms using arm span to calculate BMI rather than height . This reper se on sleep quality in children with EOS has not been reported. As the sleep quality in children with TIS is understudied, it is likely that a portion of these children are also undertreated at night both before and after surgical spine treatment.Supportive care is also important to assure sufficient high-quality sleep. Arousals from sleep are increased in 45% of children with TIS during overnight polysomnography . BIPAP iThere is published data that pre-operative pulmonary function and etiology for scoliosis can predict the risk of post-operative complications after spine fusion surgery. Among 298 patients who underwent spine fusion for idiopathic and/or congenital scoliosis, a pre-operative value for FVC <40% tripled the risk for post-operative pulmonary complications . Yuan etThe pulmonologist must monitor the impact of different surgical strategies using different surgical devices to know when surgery improves or worsens lung function. Such monitoring before and after spine fusion surgery in adolescent idiopathic scoliosis demonstrated that the posterior surgical approach had smaller adverse effects of breathing post-operatively than did an anterior approach or combined anterior-posterior approach to spine fusion . This haIn some children, lung function will progressively decline despite spine surgery with growing rods, particularly if progressive spine rotation is a prominent feature of the deformity. Demonstration of progressive loss of lung function may require an alternative surgical strategy, e.g., spine fusion, and this will be dictated by serial lung function measurements interpreted by the pulmonologist.Another role of the pulmonologist is to assure that the restrictive pulmonary disease that persists after all surgical treatment has been completed is sufficiently supported medically and that a transition plan is in place as the adolescent with TIS enters adulthood. With the advent of new prosthetic devices for the growing spine in use since 2002, a new population of patients with chronic severe restrictive respiratory disease has emerged in need of adult care. The lung function among EOS “graduates” of spine surgery is worse than among young adults who undergo surgery for adolescent idiopathic scoliosis .Children with severe TIS and/or EOS previously did not survive to adulthood. Adult issues such as occupational risks and risks during and after pregnancy have not yet been addressed in this population. Referrals to adult pulmonologists who are aware of these risks are important. Based on one series of patients with EOS that were re-evaluated 25 years after spine fusion during adolescents, progressive decline in lung function during adulthood is more likely in those with a pre-operative FVC <70% of normal .The field of spine surgery for severe spine and thoracic cage deformities which present early in life is rapidly evolving. There are now spine procedures that modulate or direct spine growth, e.g., spine tethering, staples, and the Shilla procedure . These dIn addition, the timing of surgery depends not only on progressive structural deformity of the spine but also its impact on respiratory function over time. Progressive restrictive lung disease may be an indication for intervention even if the structural progression is not dramatic. Surgical decisions among pre-adolescent children with EOS and progressive spine deformities are also controversial. Spine fusion in this age group curtails further spine growth and hence intrathoracic volume during adolescence but also reduces the frequency of complications related to further spine surgeries if growing devices are used. There is no published pulmonary data to answer this question for each of the etiologies of EOS in early childhood.There is no surgical procedure yet to salvage lung function impairment in children with TIS or EOS. Doing so remains a goal of care and may require attention to diaphragm function and position and also anterior chest wall reconstruction. Insertion of a Nuss bar to increase chest wall depth in a teenager with severe inoperable congenital scoliosis effectively relieved pulmonary artery compression and pulmonary hypertension but did not improve spirometry . New strGR was responsible for the entry of this manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Blood neurofilament light chain (NfL) is a marker of neuro-axonal injury showing promising associations with outcomes of interest in several neurological conditions. Although initially discovered and investigated in the cerebrospinal fluid (CSF), the recent development of ultrasensitive digital immunoassay technologies has enabled reliable detection in serum/plasma, obviating the need for invasive lumbar punctures for longitudinal assessment. The most evidence for utility relates to multiple sclerosis (MS) where it serves as an objective measure of both the inflammatory and degenerative pathologies that characterise this disease. In this review, we summarise the physiology and pathophysiology of neurofilaments before focusing on the technological advancements that have enabled reliable quantification of NfL in blood. As the test case for clinical translation, we then highlight important recent developments linking blood NfL levels to outcomes in MS and the next steps to be overcome before this test is adopted on a routine clinical basis. Neurofilaments are neuronal-specific heteropolymers conventionally considered to consist of a triplet of light (NfL), medium (NfM) and heavy (NfH) chains according to their molecular mass . More reEach of the neurofilament proteins consists of an amino-terminal domain that is thought to regulate the formation of oligomers , a centrIn mature myelinated axons, neurofilaments are the single most abundant protein . They peDamage to central nervous system (CNS) neurons and physiologic turnover causes neurofilament release. This translates to elevated levels in the cerebrospinal fluid (CSF) and eventually blood, where the concentration reflects the rate of release from neurons  has gained the most interest as a candidate marker of outcomes in neurological diseases. This was not without contention. While the neurofilament light chain is the most abundant and soluble of the neurofilament proteins, phosphorylated neurofilament heavy chain (NfH) was initially thought to be more resistant to protease activity ,32,33. NInitial studies looking at NfL in association with neurological disease outcomes focused on CSF measurements. Although CSF is “closer” to the CNS pathologies  and NfL concentration is approximately 500-fold higher, the inconvenient and invasive lumbar puncture required severely limits its clinical utility as a frequent serial biomarker. Concentrations in the blood however were too low to be reliably measured with conventional immunoassays such as ELISA or ECL assays. It was not until recently, with the development of the Single-Molecule Assay (SiMoA), that analytical methods become sufficiently sensitive to measure the single-digit picogram per milliliter levels present in blood . This SiAs a neuron-specific marker of neurological injury, elevated NfL levels can be found in a variety of conditions that involve neuroaxonal injury in both the central and peripheral nervous system . In purIn more indolent neurodegenerative processes, early prognostication is an important clinical role. In a study of carriers and non-carriers of autosomal dominant Alzheimer’s disease, the trajectory of NfL in affected individuals compared to controls became segregated during their 30’s, long before clinical onset . ConversMultiple sclerosis is the most common neurological autoimmune disease, known for its varied clinical presentations and unpredictable clinical course . Over thAs a cross-sectional measure in groups of MS patients, the strongest evidence links high NfL levels with inflammatory endpoints such as relapses and MRI lesions ,59,60,61Other than inflammatory disease activity, an interrelated facet of MS pathology is neurodegeneration and progressive disability accrual. Conveniently, this facet of MS pathology is also objectified with NfL measurement. Patients with progressive MS have higher levels than age and sex matched patients with relapsing disease . AssociaSeveral groups have also studied the longitudinal significance of blood NfL as a serial disease monitoring/treatment response measure in prospective cohorts from clinical trials. Studies exploring the relationship of NfL kinetics with clinical relapse showed elevations beginning approximately 5 months prior to relapse with a peak at clinical onset and recovery within 4–5 months of remission . When prIn response to treatment, often related to the availability of retrospective sample sets from well-characterised groups of patients involved in seminal studies, longitudinal NfL reductions have been reported for most established treatments for relapsing MS. These include injectable therapies ,56,59,70For secondary progressive MS, reductions in NfL have been shown following siponimod , ocrelizMany groups have shown the value of NfL in the prediction of future relapses, MRI disease activity, disability worsening, MRI brain and spine atrophy and poorer cognitive outcomes ,82,83,84While NfL is the closest blood-based disease monitoring marker to clinical translation in MS, there are also other promising candidates that may provide additional information. For instance, glial fibrillary acidic protein (GFAP) is a marker of astrocytic turnover or damage that may serve more as a marker of disease progression . AlthougMeasurement of a convenient objective blood marker of neuronal injury in patients is an appealing prospect for neurologists. Analogous to the cardiologist’s troponin, neurofilament light chain is a structural axonal protein that can be detected in the blood at elevated levels in a variety of neurological disease states which can be followed longitudinally. Enabled by recent advancements in assay technologies, many consider this test to be on the verge of clinical translation in a number of different settings. Given its neuron-specific nature, but lack of disease specificity, on its own it is not a helpful diagnostic marker. However, in defined neurological conditions that require monitoring, in particular MS where we have treatments to offer, NfL is rapidly gaining traction.It seems likely that MS will represent the test case for the clinical translation of blood NfL, where it will be a greatly-needed adjunct to clinical and MRI assessment. While we already know that elevated NfL is concerning and low NfL is reassuring, a number of challenges remain before this test is ready for widespread adoption. Foremost amongst them is the need for age-adjusted normative datasets and cutoff values so that physicians can better interpret individual patient results. Key elements of neurofilament kinetics in the blood, such as blood half-life, need to be delineated to inform optimal testing frequency in clinical practice. Additionally, the ongoing efforts of multisite validation efforts will be important in standardising measurement between clinical laboratories and ensuring that any concerns of analytical validity are allayed. Nonetheless, many are optimistic that NfL could represent the first of its kind in neurology: a broadly-applicable protein biomarker that objectively reflects underlying pathology which can be harnessed to improve patient outcomes.


General practitioners (GPs) are increasingly expected to provide palliative care as ageing populations put pressure on specialist services. Some GPs, however, cite barriers to providing this care including prognostication challenges and lack of confidence. Palliative care content within clinical practice guidelines might serve as an opportunistic source of informational support to GPs. This review analysed palliative care content within Australian guidelines for life-limiting conditions to determine the extent to which it might satisfy GPs’ stated information needs and support them to provide quality end-of-life care. Six databases and guideline repositories were searched (2011–2018). Eligible guidelines were those for a GP audience and explicitly based on an appraisal of all available evidence. Content was mapped against an established palliative care domain framework (PEPSI-COLA) and quality was assessed using AGREE-II. The nine guidelines meeting inclusion criteria were heterogenous in scope and depth of palliative care domain coverage. The ‘communication’ needs domain was best addressed while patient physical and emotional needs were variably covered. Spiritual, out-of-hours, terminal care and aftercare content was scant. Few guidelines addressed areas GPs are known to find challenging or acknowledged useful decision-support tools. A template covering important domains might reduce content variability across guidelines. The World Health Organisation’s Declaration of Astana calls for palliative care to be both ‘accessible to all’ and an ‘essential component of primary healthcare worldwide’ . This emThere appears to be an expectation that GPs will increasingly provide more palliative care as the number of people reaching old age starts to exceed the capacity of specialist palliative care services ,6,7. ManGeneral practice palliative care offers benefits known to be valued by patients and their families, including accessibility, local knowledge, and relational continuity ,11,12. ITo date, there is no centralised mechanism for capturing Australian primary health care data detailing the amount of palliative care being provided by general practitioners ,24,25. WGPs worldwide cite similar barriers to providing palliative care for their patients such as system-level policies and processes that restrict consultation time and remuneration for more complex assessments or home visits ,31,32. PAustralian GPs are aware of their need for additional training in palliative care and express a willingness to undertake it ,27. TheyThe extent to which guidelines intended for a GP audience currently provide support for GP palliative care is unknown. The aim of this study was therefore to evaluate the scope of the palliative care content within current high-quality Australian guidelines for chronic life-limiting illnesses using a framework comprising the domains deemed relevant to ‘best practice,’ as well as areas of practice GPs have identified as challenging. It also investigated the messages that guidelines convey, both explicit and explicit, regarding the role of the GP in providing palliative care.This study included a systematic search for guidelines, a qualitative content analysis of guideline recommendations, and a critical appraisal of overall guideline quality.We conducted a comprehensive search for published and unpublished guidelines for chronic ‘life-limiting illnesses’, defined as conditions which might contribute directly to a person’s death . The seaProduction criteria: Australian guidelines or evidence summaries, published since 2011, and reporting their methodology in full, including how the search for evidence was conducted and the basis used to formulate recommendations . The reporting criterion was important in ensuring all included guidelines were comparable in terms of their methodological and reporting quality.Content criteria: Explicitly relevant to primary care, focused on the management of a chronic life-limiting condition in adults (≥18 years), and including content on palliative or end-of-life care.Guidelines had to meet two sets of criteria:Summarised versions of full guidelines, such as those published in journals, were not excluded providing they could independently meet eligibility criteria. This avoided any assumptions as to which version GPs might prefer to use. Screening proceeded in three stages. One reviewer (RD) screened all items for relevance based on their titles and abstracts alone. This was followed by a check of the full text of the remaining items against the production criteria (RD). Two reviewers (RD and DH) then independently screened the reduced set against the content criteria and discussed together any discrepancies.Two authors independently scored guideline quality using the validated AGREE-II tool . This prThe full-text PDFs of included guidelines were imported into NVivo . One author (RD) read full guideline content line-by-line, coding it against two pre-established, broad data nodes—one for ‘palliative/end-of-life care’ and a second for ‘communication’. The latter node was used to identify more general communication advice relevant to palliative care but not necessarily exclusive to it. Coded data were then mapped against the domains of the PEPSI-COLA palliative care framework , an aidehttps://www.goldstandardsframework.org.uk/), a resource widely implemented in general practice in the United Kingdom.We chose the PEPSI-COLA tool in the absence of an existing validated framework as it was designed specifically for GPs and is intentionally holistic and comprehensive in its structure . It therDatabase searches, conducted in the period 15–22 August 2018, identified 1201 unique resources. Screening based on title/abstract reduced this to 116 resources before full-text review against eligibility criteria produced a final set of nine guidance documents for life-limiting chronic conditions. The process is documented in a PRISMA flow diagram .The nine resources comprised five full guidelines ,53,54,55The five full guidelines were of medium to high quality, with the two dementia guidelines achieving near perfect scores. The results of the assessment are provided as Overall, no guideline covered all domains. Most recommendations within the cancer pain management guidelines were accompanied by a statement of how the recommendation was formulated, being either evidence based or consensus based. There were only a few indications within the other guidelines as to the type of recommendation being made. These ranged in type from the weakly rated ‘[p]alliative care should include symptom control …’  to the sNone of the nine guidelines for chronic life-limiting conditions recommended a comprehensive assessment for palliative care needs in line with the WHO definition of palliative care and Australia’s National Palliative Care Standards , althougConsideration for patient emotional concerns was raised by the cancer and the COPD (full) guidelines only. Advice included referring patients to a clinical psychologist for support  and to ‘Three of the nine guidelines ,54,55 adFour guidelines addressed social support needs of patients. All three dementia guidelines and the full COPD guideline advised clinicians of the importance of referring patients to social support groups, advocacy services, sources of financial and legal aid, and voluntary support. These guidelines suggested that clinicians be aware of resources available locally in the community and to provide that information in written form to patients and carers.All nine guidelines addressed this domain although each guideline had its own emphasis. The cancer guideline stressed the importance of educating patients and their families and providing verbal and written information. All three COPD guidelines focused on discussions of goals of care and formal documentation of wishes for future care, with the outcome being an ‘advanced care directive’ or ‘terminal care plan’. The three dementia guidelines centred on the need for good and clear health professional-patient communication, recommending clinicians follow specific language guidelines and undergo communication training for dementia care. Dementia guidelines also recommended that information be made available in accessible formats, calling on professional translators if necessary. Only the cancer, heart failure, and COPD (primary care) guidelines mentioned the importance of including family members and/or carers in any discussions. The dementia deprescribing guideline alone raised direct clinician-clinician liaison to ensure care continuity for the patient.Seven of the nine guidelines addressed at least one aspect of patient choice, control, or autonomy such as informed or shared decision making ,54,55, oThis domain was poorly covered by all guidelines. Only the COPD primary care guideline suggested that clinicians ‘plan for out of hours care.’ No guidelines discussed GP care for patients within the patient’s own home outside of clinic hours.Two dementia guidelines gave specific advice on managing late stage concerns such as hydration, feeding, resuscitation, and discontinuation of medication ,54. The One guideline for COPD  gave cleThe following aspects of palliative care were addressed in at least one guideline and may provide useful information to GPs with lower confidence in their understanding of, and skills in, palliative care.Two guidelines defined palliative care. One provided the full WHO definition  and the The full guideline for COPD allocated GPs a management and coordination role within a multidisciplinary care team. The COPD primary care guideline suggested that GPs develop a GP Management Plan under the Australian Medicare Benefits Scheme and arrange pharmacists to do home medicine reviews for COPD patients. The full heart failure guideline stated that GPs have a ‘vital role’ in patient management and the collaborative care model.COPD guidelines emphasised the importance of a multidisciplinary team approach in palliative care which includes the primary care team. The heart failure guideline (full) came at this another way, addressing the specialist palliative care in advising it to work collaboratively with the patient’s GP.The full COPD guideline provided comprehensive advice on clinical indicators which might be used to initiate a review of the goals of care. It also acknowledged the challenging nature of prognosticating for COPD, suggesting palliative care initiation should not, therefore, be dependent on making an accurate diagnosis. The primary care version of the same guideline was equally as descriptive but added in the well-known ‘surprise question’ for GP consideration. The heart failure guidelines provided statistics and some general guidance on what clinicians might look for as suggestive of a change in the disease trajectory. No guideline recommended established disease-specific or generalisable tools for prognostication.While the COPD guidelines for primary care described anticipatory end of life care planning in detail, the two heart failure guidelines stressed the importance of involving ‘palliative care’ early in the trajectory towards end-stage heart failure.The COPD journal summary included a statement on the benefits of palliative care in its main recommendations.Clinical practice guidelines have an important educative role and, by encouraging clinicians to follow ‘best’ available practice, can build capacity and raise the quality of care . This quDespite GP uncertainty as to what constitutes palliative care , when itStandard 5 of Australia’s National Palliative Care Standards stresses the importance of establishing seamless and integrated care within and between services, stating: ‘[w]hen working in partnership with other services, clear strategies for referral, communication and designated areas of responsibility are essential.’ Although the guidelines analysed originated within the same country, they provided differing advice on the timing and responsibility for referring patients to specialist care, often without clarifying explanation or mention of a needs-based assessment. One guideline simply directed clinicians to ‘refer to palliative care’ , while aThis study confirms findings that emotional and spiritual domains are often lightly addressed, if at all, in guidelines . This apThe GP appears as an important ‘collaborative’ team member during the active treatment phase; however, the role is less clear during the palliative care phase, varying from service coordination, symptom management, or simple referrer. Although all guidelines were situated within the same national context, no guideline addressed the importance of having an effective continuum of palliative care within the Australian health care system which includes the general practitioner. Until the GP role in palliative care is clarified along with the domains and processes that fall within the GP’s remit, there seems little benefit to discussions of how to assess GP competence in providing palliative care . This hawhat to do with practical resources advising how to do it arguably provides GPs with more useful guidance than long resources focused purely on providing a precise appraisal of published research studies.Overall, there was considerable heterogeneity across guidelines as to domains covered and domain elements emphasised. Despite access to the same evidence base, no two guidelines made similar recommendations on the same aspect of care, differing in content, scope and directiveness. Summary versions of full guidelines also differed in the amount and type of information they conveyed, generally omitting much of the palliative care content. Whilst space constraints make this understandable, this still matters if time-poor GPs rely on shorter, more readily accessible guidelines rather than the considerably more informative full versions. Despite being the longest of the guideline summaries, the COPD concise guide for primary care  combinesIn crafting end-of-life guidance, guideline developers and their authorship teams have available to them a considerable body of evidence describing the barriers faced by GPs in providing palliative care to their patients. They might then proactively address those barriers relating to skills, confidence, and knowledge by providing information and guidance in the areas where GPs express uncertainty such as prognostication and timing of referral. General practitioners are already well suited to provide palliative care. They have the benefit of being able to draw on knowledge of a patient and his/her family gained through relational and longitudinal care continuity. Their holistic, biopsychosocial understanding of the illness experience also fits well with the goals and ethos of palliative care. Guidelines might highlight these strengths alongside others to bolster GP confidence in providing palliative care. Furthermore, in clarifying the GP’s role and the complementary roles played by other health care professionals, they might also describe an integrated system where the various players work together, rather than on their own, to create seamless care experiences for families.Incorporating more of the domains closely associated with palliative care might also strengthen the quality of palliative care guideline content for general practitioners. This could be achieved by developing a template for palliative care content based on discussion and consensus between stakeholders including guideline developers, GPs, medical specialists, members of specialist palliative care teams, as well as patients, and their family/carers. This template could be adaptable to fit any guideline development project with scope to customise for disease-specific factors. This has been done previously with the creation of template that intercalates palliative care considerations across the full range of the guideline, rather than leaving it until the end of the document .This study is based on a comprehensive search for and analysis of guidelines in one national context only. However, given anticipated increases in ageing populations, multimorbidity, and expected deaths worldwide, it may be timely for international guideline groups to consider the strength and utility of the palliative content within their own guidelines.a priori framework commonly used within palliative care to assess individual patient needs. The analysis was also situated within the context of two existing discourses on the topic of GP involvement in palliative care provision: (1) the expectations of prominent health organisations such as WHO; and (2) GP reports on their own levels of confidence and engagement.This study took an objective approach to analysing the scope and potential utility of palliative care guidance by adopting an This study does make several basic assumptions. Firstly, that single disease guidelines are the appropriate place for guidance on palliative care, especially patient-centred aspects such as communication which may not be supported by strong empirical evidence. Perhaps referencing standalone palliative care guidelines, where they exist, is a more effective way to ensure that this important aspect of care is adequately covered. Development of these guidelines might be based on different evidentiary and knowledge foundations than disease-specific ones, offering more flexibility in the range of topics they can cover. The palliative care guidance in the RACGP Aged Care Clinical Guide is an example of this approach .Another assumption is that the PEPSI-COLA domains adequately reflect the aspects of care GPs are happy to provide and which patients feel comfortable in receiving. Spiritual care is a case in point. Patients are often not aware that this might be a topic they can raise with their GP . Perhaps


Pediatric venous disease is increasing in incidence in both inpatient and outpatient populations. The widespread use of central venous access devices as well as the rising incidence of thromboembolic events in pediatrics is leading to more systemic venous occlusions in both the central and peripheral veins. This review focuses on the etiology, presentation, workup, and general technical considerations of recanalization as well as procedural complications related to pediatric systemic venous occlusive disease. The potential role for pediatric interventional radiology guided treatments will be discussed in detail. Systemic venous occlusions (SVO) are an important subset of pediatric vascular disease. These can be congenital or acquired, the latter is often associated with long-term central venous catheters. Occlusions can be partial or complete and can result in fewer options for central venous access, deep vein thrombosis (DVT) and pulmonary embolism, and peripheral symptoms such as arm or leg swelling. The ability to successfully recanalize pediatric SVOs and perform thrombectomy when appropriate is paramount.Barriers to successful management of SVOs in children include unfamiliarity with congenitally altered venous anatomy or the small patient, unfamiliarity with pediatric dosing of anticoagulants and thrombolytic drugs, unavailability of suitable equipment, and a perceived sense of heightened risk for recanalization procedures in children.In this review, we discuss the etiology and presentation of SVOs in children, periprocedural medical management, general technical considerations of recanalization, strategies for addressing both acute and chronic or congenital occlusions, and procedural complications.The overall prevalence of SVO in children is difficult to ascertain because most children with these types of occlusions are asymptomatic  distributions, deep vein thrombosis from hypercoagulability (e.g. Factor V Leiden deficiency) or mechanical obstruction (e.g. May-Thurner syndrome), and trauma. Distinguishing between congenital and acquired SVO is sometimes a diagnostic challenge especially if children do not present with symptoms of venous obstruction until later in life. However, making this distinction is critical because recanalization of congenital SVO is often impossible or may require aggressive techniques such as stent construction of a non-anatomic vascular channel. On the other hand, if an obstructed pathway is still present, even if diminutive from chronic obstruction and scarring, anatomic recanalization may be feasible. In the authors’ experience, reconstruction of native vasculature is associated with greater long-term patency compared to neovessel construction.Clinical presentation of SVO in children usually involves swelling of the affected extremity due to impedance of venous return. Head and neck swelling can occur in advanced SVC obstruction. Presence of superficial venous engorgement can also be present in long-standing obstruction. In acute obstruction due to DVT or complete catheter-associated obstruction in the immediate post-procedural period, venous ischemia can occur. Findings may range in severity from swelling of the extremity and diminished pulses or prolonged capillary refill time, coolness and blue limb discoloration to frank venous ischemia in the threatened limb, classically associated with the physical exam finding of phlegmasia cerulea dolens Fig. . AdolescCommon vessel systems involved include the femoropopliteal and iliac distribution, SVC and innominate veins, and IVC  examination, which can often be performed in the awake patient. For peripheral disease, most children and adolescents can be adequately evaluated for thrombotic occlusion of major vessels, absence of major conducting pathways, presence of large aberrant channels, and venous reflux. Evaluation of the SVC and IVC is often limited. In the post-intervention setting, Doppler US is used to monitor patients for maintenance of vessel patency following recanalization. Extensive collateral networks are usually not well-evaluated with Doppler US because of the limited field of view of this type of examination.Contrast-enhanced computed tomography (CECT) is obtained to evaluate central distributions of SVO that are not well-imaged with US, such as in the SVC or upper IVC, as well as to evaluate for atretic or scarred channels and map collateral pathways. Concomitant evaluation for pulmonary embolism can also been obtained with CECT pulmonary angiography in cases where there is concern for DVT. In May-Thurner syndrome, CECT can delineate compression of the left common iliac vein by the crossing right common iliac artery as well as provide for vessel measurement and other aspects of pre-intervention planning. In cases where stent placement is indicated, cross-sectional imaging offers the ability to estimate vessel length and diameter, though caution should be undertaken as underfilling of a vessel upstream from an occlusion may falsely underestimate its true size. Post-stent insertion, CECT can delineate stent patency, intra-stent stenosis, and configuration. Increasingly, cone beam CT (CBCT) is used intra-procedurally to assess for stent apposition or evaluate for the presence of procedural complications.Contrast-enhanced magnetic resonance imaging (MRI) and dynamic MR venography (MRV) is useful for lower extremity and abdominal/pelvic evaluation, especially in patients with long standing disease from congenital anatomic alteration Fig. a or compThere are basic technical principles that are fundamental to recanalization of any SVO in pediatric or adult patients. Review of all available cross-sectional imaging should be performed to plan for recanalization. Degree of stenosis, presence of collateral pathways, venous thrombosis, and vessel size are examples of considerations that should be evaluated prior to recanalization/stenting. Long-segment or chronic occlusions with obliteration of anatomic pathways pose a risk of procedural failure as well as increased risk of complications from aggressive attempts at recanalization.First, a high quality digital subtraction angiogram (DSA) should be performed of the region of interest which is free from motion and other artifact. An assessment of whether the occlusion is congenital or acquired, partial or complete, and the presence of collateral pathways should be performed as these considerations will determine the likelihood of success and the degree of aggressiveness that may be undertaken. Once the DSA has been performed, subtraction roadmap overlay is often used to guide catheter and wire passage centrally. Initial attempts at recanalization are often achieved with an angled, hydrophilic, diagnostic catheter  placed over a hydrophilic 0.018 or 0.035 in. wire. Careful attention should be paid to extraluminal wire perforation.Planning of access points during recanalization should include consideration of whether access on either side of the occlusion is necessary. For central occlusions, such as in the SVC or IVC, access from both above and below may be necessary to achieve stable positioning for devices. After the secondary access has been obtained, an intravascular snare is used to grasp the floppy end of the wire and pull it out through the primary access, resulting in “flossed” access. When placing a sheath, it may be helpful to nest a small sheath within the larger access sheath to achieve more stability in the region of interest. Sheath size should be selected according to the size of balloon or stent that is required.In addition to DSA imaging, adjunctive intraprocedural imaging modalities include intravascular ultrasound (IVUS) imaging to better characterize vessel diameter and check for stent apposition, and noncontrast or contrast-enhanced cone beam computed tomography (CBCT). Modern angiographic systems also allow for needle targeting using CBCT navigational overlay upon conventional fluoroscopy, which can be employed to achieve difficult access into target vessels for recanalization.General principles of venous recanalization are mentioned below with greater detail in the subsequent sections. For acute or short-segment venous stenosis or occlusion, balloon angioplasty followed by maintaining the patient on systemic antiplatelet therapy or anticoagulation may be sufficient for maintenance of patency. However, for chronic or long segment occlusions, stent placement is usually indicated. Pharmacomechanical thrombolysis or thrombectomy should be performed in acute thrombotic SVO  are typically related to acute thromboembolism and etiologies of acute venous occlusions have been well described in numerous publications  range from surgical bypass grafts to prosthetic graft reconstruction to endovascular angioplasty and stenting . The planning venogram must be scrutinized for the best approach and direction to cross the occlusion: the length of occlusion, the trajectory, and any at risk adjacent structures while crossing the occluded portion of the vessel . The needle can be guided through a direct percutaneous approach (through the skin into the patent vessel and across the occlusion) or via a catheter coaxially loaded into a vascular sheath . If the direct percutaneous route is chosen for sharp recanalization, a 0.018″ or 0.014″ wire is directly passed into the central, patent vein . The use of intravascular ultrasound (IVUS) has lessened the risk of sharp venous recanalizations. The IVUS-assisted technique for chronic venous occlusions was adapted from the well-described use of IVUS in transjugular intrahepatic portosystemic shunt (TIPS) creation , Dorado , Atlas , and Powerflex  are often used; sizing is based on venograms and IVUS measurements of the vessels flanking the occlusion.Once a patent channel has been established, stenting is usually performed if the child is skeletally mature and the location of the proposed stents is conducive to stenting. If the child is not skeletally mature, stents can still be considered in the supradiaphragmatic region  as long as the stent complex can be serially ballooned to a larger caliber over time. This is often achieved with placing a self-expanding stent through a balloon mounted stent; the overall stent diameter is thereby constrained by the smaller, balloon-expandable stent. The “hourglass” shaped, constrained stent complex will provide a controlled expansion with follow up angioplasty procedures to expand the total stent diameter as the child grows (Image 7E). If the location of the occlusion is not amenable to stent placement (near a joint or in the extremity) or if the child is not skeletally mature, repeat balloon angioplasty, potentially with drug eluting balloons, and prophylactic anticoagulation is considered the safest treatment (Image 3D).SVO which typically require stent placement for long term patency include SVC, IVC, and iliac veins (May Thurner). Common stents used in these locations include Wallstent , Palmaz , Viabahn , S.M.A.R.T. Control stent , and the recently introduced Venovo  and Vici stent . Only in select circumstances, stents are deployed below the inguinal ligament. Van Vuuren et al. described experience in stenting into the common femoral vein in 79 adult patients. Fourteen of the 79 patients had primary stent placement for post-thrombotic changes that extended peripherally to the femoral confluence, but the deep femoral vein had to provide the majority of venous inflow in order to maintain stent patency  with dual anti-platelet agents  where clopidogrel was only used for 2 months following stent placement  and stent placement are not well reported in the literature as there are predominantly case reports with no translatable data for larger patient groups. Primary patency rates in pediatric patients with IVC and iliac vein stents range from 64 to 100% in the first 12 months following stent placement , and any adjacent tissue damage. Plans to immediately respond to this type of complication should be made and resuscitation equipment readily available if the need arises. Typically, an angioplasty balloon can be inflated for a prolonged time (3 min of sustained inflation) across the vessel injury with subsequent venogram and/or IVUS to prove there is no further extravasation .In summary, SVO in pediatrics is increasing in incidence due to better detection of congenital occurrences as well as increased utilization of central venous devices and venous thromboembolic disease. Interventional radiology is often consulted for difficult central venous access cases and must be ready to suggest a life-saving option such as venous recanalization when feasible. Acute thrombotic occlusions are typically treated with pharmacomechanical thrombolysis, angioplasty, and possible stent placement and if aggressively treated, may allow the child to have a lifelong course of vessel patency. Chronic venous occlusions can prove to be a more challenging problem but attempts at recanalization through various endovascular techniques and maneuvers can be beneficial. The data regarding stent patency is limited at best in the pediatric world and further studies better delineating the anticoagulation regimens and principles for long term stent management are very much needed.