Overcoming the barriers to implementing urban road user charging schemes

Urban road user charging offers the potential to achieve significant improvements in urban transport, but is notoriously difficult to implement. Cities need guidance on the range of factors to be considered in planning and implementing such schemes. This paper summarises the results of a 3 year programme which has collated evidence on the issues of most concern to cities. A state of the art report has provided evidence on 14 themes, ranging from objectives and design to implementation and evaluation. A set of 16 case studies has reviewed experience in design and implementation across Europe. The paper summarises their findings, provides references to more detailed information, presents the resulting policy recommendations to European, national and local government, and outlines the areas in which further research is needed

The effect of prior walking on coronary heart disease risk markers in South Asian and European men.

Purpose: Heart disease risk is elevated in South Asians possibly due to impaired postprandial metabolism. Running has been shown to induce greater reductions in postprandial lipaemia in South Asian than European men but the effect of walking in South Asians is unknown. Methods: Fifteen South Asian and 14 White European men aged 19-30 years completed two, 2-d trials in a randomised crossover design. On day 1, participants rested (control) or walked for 60 min at approximately 50% maximum oxygen uptake (exercise). On day 2, participants rested and consumed two high fat meals over a 9h period during which 14 venous blood samples were collected. Results: South Asians exhibited higher postprandial triacylglycerol (geometric mean (95% confidence interval) 2.29(1.82 to 2.89) vs. 1.54(1.21 to 1.96) mmol·L-1·hr-1), glucose (5.49(5.21 to 5.79) vs. 5.05(4.78 to 5.33) mmol·L-1·hr-1), insulin (32.9(25.7 to 42.1) vs. 18.3(14.2 to 23.7) µU·mL-1·hr-1) and interleukin-6 (2.44(1.61 to 3.67) vs. 1.04(0.68 to 1.59) pg·mL-1·hr-1) than Europeans (all ES ≥ 0.72, P≤0.03). Between-group differences in triacylglycerol, glucose and insulin were not significant after controlling for age and percentage body fat. Walking reduced postprandial triacylglycerol (1.79(1.52 to 2.12) vs. 1.97(1.67 to 2.33) mmol·L-1·hr-1) and insulin (21.0(17.0 to 26.0) vs. 28.7(23.2 to 35.4) µU·mL-1·hr-1) (all ES ≥ 0.23. P≤0.01), but group differences were not significant. Conclusions: Healthy South Asians exhibited impaired postprandial metabolism compared with White Europeans, but these differences were diminished after controlling for potential confounders. The small-moderate reduction in postprandial triacylglycerol and insulin after brisk walking was not different between the ethnicities

Guidelines for Acquisition, Interpretation, and Reporting of Whole-Body MRI in Myeloma: Myeloma Response Assessment and Diagnosis System (MY-RADS).

Acknowledging the increasingly important role of whole-body MRI for directing patient care in myeloma, a multidisciplinary, international, and expert panel of radiologists, medical physicists, and hematologists with specific expertise in whole-body MRI in myeloma convened to discuss the technical performance standards, merits, and limitations of currently available imaging methods. Following guidance from the International Myeloma Working Group and the National Institute for Clinical Excellence in the United Kingdom, the Myeloma Response Assessment and Diagnosis System (or MY-RADS) imaging recommendations are designed to promote standardization and diminish variations in the acquisition, interpretation, and reporting of whole-body MRI in myeloma and allow response assessment. This consensus proposes a core clinical protocol for whole-body MRI and an extended protocol for advanced assessments. Published under a CC BY 4.0 license. Online supplemental material is available for this article

Extracranial soft-tissue Tumors: repeatability of apparent diffusion coefficient estimates from diffusion-weighted MR imaging

Purpose To assess the repeatability of apparent diffusion coefficient (ADC) estimates in extracranial soft-tissue diffusion-weighted magnetic resonance imaging across a wide range of imaging protocols and patient populations. Materials and Methods Nine prospective patient studies and one prospective volunteer study, performed between 2006 and 2016 with research ethics committee approval and written informed consent from each subject, were included in this single-institution study. A total of 141 tumors and healthy organs were imaged twice (interval between repeated examinations, 45 minutes to 10 days, depending the on study) to assess the repeatability of median and mean ADC estimates. The Levene test was used to determine whether ADC repeatability differed between studies. The Pearson linear correlation coefficient was used to assess correlation between coefficient of variation (CoV) and the year the study started, study size, and volumes of tumors and healthy organs. The repeatability of ADC estimates from small, medium, and large tumors and healthy organs was assessed irrespective of study, and the Levene test was used to determine whether ADC repeatability differed between these groups. Results CoV aggregated across all studies was 4.1% (range for each study, 1.7%–6.5%). No correlation was observed between CoV and the year the study started or study size. CoV was weakly correlated with volume (r = −0.5, P = .1). Repeatability was significantly different between small, medium, and large tumors (P < .05), with the lowest CoV (2.6%) for large tumors. There was a significant difference in repeatability between studies—a difference that did not persist after the study with the largest tumors was excluded. Conclusion ADC is a robust imaging metric with excellent repeatability in extracranial soft tissues across a wide range of tumor sites, sizes, patient populations, and imaging protocol variations

Genetic mechanisms of critical illness in COVID-19.

Host-mediated lung inflammation is present1, and drives mortality2, in the critical illness caused by coronavirus disease 2019 (COVID-19). Host genetic variants associated with critical illness may identify mechanistic targets for therapeutic development3. Here we report the results of the GenOMICC (Genetics Of Mortality In Critical Care) genome-wide association study in 2,244 critically ill patients with COVID-19 from 208 UK intensive care units. We have identified and replicated the following new genome-wide significant associations: on chromosome 12q24.13 (rs10735079, P = 1.65 × 10-8) in a gene cluster that encodes antiviral restriction enzyme activators (OAS1, OAS2 and OAS3); on chromosome 19p13.2 (rs74956615, P = 2.3 × 10-8) near the gene that encodes tyrosine kinase 2 (TYK2); on chromosome 19p13.3 (rs2109069, P = 3.98 ×  10-12) within the gene that encodes dipeptidyl peptidase 9 (DPP9); and on chromosome 21q22.1 (rs2236757, P = 4.99 × 10-8) in the interferon receptor gene IFNAR2. We identified potential targets for repurposing of licensed medications: using Mendelian randomization, we found evidence that low expression of IFNAR2, or high expression of TYK2, are associated with life-threatening disease; and transcriptome-wide association in lung tissue revealed that high expression of the monocyte-macrophage chemotactic receptor CCR2 is associated with severe COVID-19. Our results identify robust genetic signals relating to key host antiviral defence mechanisms and mediators of inflammatory organ damage in COVID-19. Both mechanisms may be amenable to targeted treatment with existing drugs. However, large-scale randomized clinical trials will be essential before any change to clinical practice

Whole-genome sequencing reveals host factors underlying critical COVID-19

Critical COVID-19 is caused by immune-mediated inflammatory lung injury. Host genetic variation influences the development of illness requiring critical care1 or hospitalization2–4 after infection with SARS-CoV-2. The GenOMICC (Genetics of Mortality in Critical Care) study enables the comparison of genomes from individuals who are critically ill with those of population controls to find underlying disease mechanisms. Here we use whole-genome sequencing in 7,491 critically ill individuals compared with 48,400 controls to discover and replicate 23 independent variants that significantly predispose to critical COVID-19. We identify 16 new independent associations, including variants within genes that are involved in interferon signalling (IL10RB and PLSCR1), leucocyte differentiation (BCL11A) and blood-type antigen secretor status (FUT2). Using transcriptome-wide association and colocalization to infer the effect of gene expression on disease severity, we find evidence that implicates multiple genes—including reduced expression of a membrane flippase (ATP11A), and increased expression of a mucin (MUC1)—in critical disease. Mendelian randomization provides evidence in support of causal roles for myeloid cell adhesion molecules (SELE, ICAM5 and CD209) and the coagulation factor F8, all of which are potentially druggable targets. Our results are broadly consistent with a multi-component model of COVID-19 pathophysiology, in which at least two distinct mechanisms can predispose to life-threatening disease: failure to control viral replication; or an enhanced tendency towards pulmonary inflammation and intravascular coagulation. We show that comparison between cases of critical illness and population controls is highly efficient for the detection of therapeutically relevant mechanisms of disease

CpG binding protein (CFP1) occupies open chromatin regions of active genes, including enhancers and non-CpG islands

Additional file 1. Fig. S1: Analysis of CFP1 binding at individual loci and CpG islands (CGIs). (A-B) Analysis of CFP1 binding at the human α-globin locus in expressing and non-expressing cells. (A) Real-Time PCR analysis of immunoprecipitated chromatin using CFP1 antibody in human erythroblasts (red) and B-lymphocytes (blue). The y-axis represents enrichment over the input DNA, normalised to a control sequence in the human 18S gene. The x-axis represents the positions of Taqman probes used. The coding sequence is represented by the three exons (Promoter/Ex1, Ex2, Ex3) of the α-globin genes. 218 and hBact denote control sequences adjacent to the CpG islands of the human LUC7L (218) and ACTB promoters. Error bars correspond to ± 1 SD from at least two independent ChIPs. (B) Real-Time PCR analysis of immunoprecipitated chromatin using the CFP1 antibody indicated in humanised erythroblasts (normal, +MCS-R2 (left) and mutant, MCS-R2 (right). The y-axis represents enrichment over the input DNA, normalised to a control sequence in the mouse GAPDH gene. CpG Act denotes additional control sequence at the CGI of the mouse ACTB gene. The amplicons highlighted in red represent deleted regions in the humanised mice, for which no PCR signal is observed. Error bars correspond to ± 1 SD from at least two independent ChIPs. (C) CFP1 ChIP signal intensity in the top 200 peaks, by antibody and by cell type. Abcam, ab56035 antibody. Roeder, main antibody used in this study. (D) Analysis of CGI (green) and non-CGI (blue) transcription start sites (1-kb window, centred on TSS). Gene symbols shown with CpG content of individual loci in parentheses. Greek letters represent individual globin genes. Fig. S2: Peak overlaps of CFP1 and marks of active and repressed chromatin in transcription start sites (TSSs). Peaks were detected by MACS2. Venn diagrams show that CFP1 peaks within 1-kb of TSSs are strongly associated with H3K4me3 histone mark and poorly associated with H3K27me3 repressive histone mark. Cell types are (A) ERY and (B) EBV. Public data sets: * NCBI GEO GSE36985, ** NCBI GEO GSE50893. Fig. S3: UCSC tracks showing CFP1 and other ChIP signals in gene loci in erythroblasts (ERY) and EBV-transformed B-lymphoblasts (EBV). Hg38 coordinates for multiple genes, CpG islands (CGI, green boxes), and putative regulatory regions (blue boxes) are shown. CFP1 signals are shown in dark reds, inputs in grey, histone H3 signals in blues and open chromatin marks in greens. All ChIP pileups are scaled to 1x coverage genome-wide and shown in a range 0–50, except CFP1 (Roeder) is shown with extended range and H3K27me3 graphs scaled by 2x. (A) Tissue-specific binding of CFP1 to CGI promoters of tissue-specifically expressed genes. Left (chr16), CGI promoters of active genes in alpha globin locus are CFP1-bound in ERY, and unbound in EBV. Flanking regions are included, with known tissue-specific enhancers. Right (chr6), first seven exons of IRF4 locus, active in EBV and inactive in ERY, with CFP1 binding to CGI promoter in EBV only. (B) CGI promoters of housekeeping genes are CFP1 bound and unmarked by H3K27me3. Left (chr7), ACTB locus. Right (chr16), LUC7L locus. (C) CGI promoter of RHBDF1 locus (chr16) has H3K27me3 mark and the absence of CFP1 binding in both ERY and EBV. Fig. S4: Western blot analysis of CGBP (CFP1) expression in mouse and human erythroid and human lymphoid cell types. Whole cell extracts (20 µg) were loaded in each lane (1) mouse ES, (2) U-MEL, (3) I-MEL, (4) mouse primary erythroblasts and (5) human primary T lymphocytes and (6) human primary erythroblasts and separated on a 10% SDS-polyacrylamide gel. CFP1 antibody was used at a 1:1000 dilution. Fig. S5: Similar cell type-specific CFP1 read depth at CGI TSS of HBA1 gene and non-CGI TSS of HBB gene. Upper two tracks use the main antibody, and second two tracks use the commercial antibody. Coordinates are from the hg38 human genome build. Read depths are averaged in 50 bp bins and normalised to 1x genome-wide coverage. Blue boxes, known regulatory regions; green box, CGI. Fig. S6: Distribution of TrxG components in erythroid cells. Green indicates CGI and blue indicates other putative regulatory regions. All loci transcribed right to left. Pileups are shown scaled to 1x genome coverage, with full scale 0–50x depth. (A) Housekeeping genes ACTB, left (chr7), and LUC7L, right (chr16). (B) β-globin locus (chr11), (C) Non-expressed RHBDF1 locus (chr16). Fig. S7: Overlap of TrxG subunit ChIP peaks in a high-confidence subset of regions. SET1A complexes are represented by CFP1-SET1A colocalisation. MLL1/2 complexes are represented by Menin, and MLL3/4 complexes are represented by UTX, respectively. HCF1 is found in SET1A/B and MLL1/2 complexes, and RBBP5 is a member of SET1A/B and MLL1/2/3/4 complexes. Red outline (4220 peaks) shows strong colocalisation of Menin and CFP1-SET1A, accounting for the vast majority (99.5%) of 4242 CFP1-SET1A and half (50.0%) of 8432 Menin peak regions. Majority (87.0%, 2089/2400 peaks) of HCF1 (blue region) is accounted for by approximately half (49.5%, 2089/4220) of regions of Menin-SET1A-CFP1 colocalisation. Regions where either SET1A-CFP1 or Menin or both are colocalised with HCF1 (blue dashed line) accounts for nearly all (99.6%, 2390/2400) HCF1 regions, suggesting that HCF1 bound to DNA is primarily present as part of SET1A/B or MLL1/2 complexes. Fig. S8: Chromatin accessibility in TSSs and enhancers in erythroid cells as measured by ATAC-seq and DNase-seq. 1x-normalised, input-subtracted signals from ATAC-seq and DNase were averaged in a 2-kb window about TSSs and putative enhancers. Z-score transformed values for ATAC-seq and DNase-seq at a given locus were averaged. Fig. S9: Relationship of CFP1 signal to three predictive factors in top-decile open chromatin regions. A linear combination of CpG density and SET1A and H3K4me3 ChIP signals explains a substantial fraction of variation in CFP1 ChIP signal. Table S1: Bias of CFP1 for CGI TSSs in cell types and gene classes. Table S2: Bias of CFP1 for housekeeping gene TSSs. Table S3: Motifs associated with CFP1 peaks. Table S4: Dependence of CFP1 ChIP signal in erythroid cells on covariates putatively associated with its binding. Table S5: Analysis of variance of CFP1 signal in top-decile open chromatin regions surrounding TSSs and putative enhancers

Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses

To understand neurological complications of COVID-19 better both acutely and for recovery, we measured markers of brain injury, inflammatory mediators, and autoantibodies in 203 hospitalised participants; 111 with acute sera (1–11 days post-admission) and 92 convalescent sera (56 with COVID-19-associated neurological diagnoses). Here we show that compared to 60 uninfected controls, tTau, GFAP, NfL, and UCH-L1 are increased with COVID-19 infection at acute timepoints and NfL and GFAP are significantly higher in participants with neurological complications. Inflammatory mediators (IL-6, IL-12p40, HGF, M-CSF, CCL2, and IL-1RA) are associated with both altered consciousness and markers of brain injury. Autoantibodies are more common in COVID-19 than controls and some (including against MYL7, UCH-L1, and GRIN3B) are more frequent with altered consciousness. Additionally, convalescent participants with neurological complications show elevated GFAP and NfL, unrelated to attenuated systemic inflammatory mediators and to autoantibody responses. Overall, neurological complications of COVID-19 are associated with evidence of neuroglial injury in both acute and late disease and these correlate with dysregulated innate and adaptive immune responses acutely

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570