Laparoscopic-assisted percutaneous endoscopic gastrostomy: Insertion of a skin-level device using a tear-away sheath

Background: This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KEY) in a single procedure. Methods: We identified infants, children and young adults who underwent laparoscopicassisted percutaneous endoscopic gastrostomy (LAPEG) tube insertion between October 2009 and June 2013. The steps of this procedure include upper endoscopy, single-port laparoscopy, gastropexy via percutaneous T-fasteners and placement of a skin-level gastrostomy device (MIC-KEY) using a push technique with a tearaway sheath. Results: We included 92 patients in our study. Mean age was 3.7 years (range 3 wk- 5 yr), and mean weight was 11.2 (range 2.8-54) kg. Median procedural time was 20 (range 12-76) minutes. Total median duration for the most recent 25 procedures was lower than that of the first 25 (62 v. 79 min, p = 0.004). There were no intraoperative complications or conversions to open surgery. Postoperative complications were observed in 6 (6.5%) patients. Three retained T-fasteners were assessed endoscopically (n = 1) or removed via local excision (n = 2). Two patients experienced early dislodged feeding tubes that were replaced via interventional radiology (n = 1) or repeat LAPEG (n = 1). There was also 1 intra-abdominal fluid collection that was drained percutaneously but ultimately required a laparotomy and washout. There were no major complications in the most recent 50 procedures. Conclusion: Our results suggest that LAPEG is a safe, minimally invasive procedure for infants, children and young adults. This approach allows for immediate use of a skin-level gastrostomy device without the need for postoperative tube exchanges

Heterogeneity in progression of prodromal features in Parkinson’s disease

Background: In the pre-diagnostic phase of Parkinson’s disease (PD), a range of motor and non-motor symptoms can occur. However, there is considerable variability in their onset and currently little information exists on the pattern of progression of clinical features before diagnosis. Methods: We analysed data from a survey amongst patients with PD from 11 European countries by the European Parkinson’s Disease Association. They completed questions on first occurrence of 21 pre-diagnostic features. A principal component analysis (PCA) with varimax rotation was performed to determine the co-occurrence of these features. Findings: 1,467 patients were included. Changes in movement were the most commonly reported features up to 4 years before diagnosis. However, at five or more years before diagnosis loss of sense of smell, sleep problems, fatigue and other non-motor features had been experienced most frequently. PCA of pre-diagnostic features’ duration revealed three factors with eigenvalues over Kaiser’s criterion of 1: a) a neuropsychiatric factor comprised of anxiety, depression, apathy, stress, and sleep problems; b) an axial factor defined by difficulty eating and/or swallowing problems, freezing, and falls/balance problems; and c) a motor factor with additional non-motor features. Bladder/bowel problems and tremor had low factor loadings on all components. However, in those with disease duration less than 5 years the autonomic features were associated with the axial factor and tremor loaded on both the motor and psychiatric symptom factors. Interpretation: The identified symptom complexes in the pre-diagnostic stage of PD may be reflective of a shared pattern of pathological disease progression

Cyclic AMP Regulation of Protein Lysine Acetylation in Mycobacterium Tuberculosis

Protein lysine acetylation networks can regulate central processes such as carbon metabolism and gene expression in bacteria. In Escherichia coli, cyclic-AMP (cAMP) regulates protein lysine acetyltransferase (PAT) activity at the transcriptional level, but in Mycobacterium tuberculosis, fusion of a cyclic-nucleotide binding domain to a Gcn5-like PAT domain enables direct cAMP control of protein acetylation. Here we describe the allosteric activation mechanism of M. tuberculosis PAT. The crystal structures of the auto-inhibited and cAMP-activated PAT reveal that cAMP binds to a cryptic site in the regulatory domain over 32 Å from the catalytic site. An extensive conformational rearrangement relieves auto-inhibition by a substrate-mimicking lid that covers the protein-substrate binding surface. A steric double latch couples the domains by harnessing a classic, cAMP-mediated, conformational switch. The structures suggest general features that enable the evolution of long-range communication between linked domains

Rapid, cost-effective and scalable gmp-compliant simian adenovirus-vectored vaccine production for early-phase clinical trials using entirely disposable product-contact components

The Jenner Institute, University of Oxford, develops and produces a range of vaccines against emerging threats (such as Zika) and current global health challenges (including malaria, HIV and rabies). The Jenner Clinical Biomanufacturing Facility (CBF) manufactures multiple simian adenovirus-vectored vaccines for early phase clinical trials each year. Hitherto we have used shake flasks for upstream production and caesium chloride gradient ultracentrifugation for downstream purification. This process is robust and simple but also slow, human resource intensive and lacks scalability. Here we report the development of a novel process using a 2 x 3L single-use stirred tank bioreactor system (MilliporeSigma Mobius®), coupled to a tangential flow filtration (TFF) and anion exchange chromatography (AEX)-based downstream process. The process also includes particle lysis and nucleic acid digestion inside the bioreactor, as well as clarification of cells and debris using depth filters. As our test case, we used a novel simian adenovirus-vectored rabies vaccine (ChAdOx2 RabG), which we will manufacture to GMP standards in the coming year. Each process run yields \u3e5x1013 ChAdOx2 RabG virus particles (approximately 1000 human doses), with residual host cell DNA, host cell protein and nuclease levels suitable for clinical trial use. While similar processes have been previously reported for adenovirus manufacture, we will report a number of points of novelty. Firstly, we use single-use disposable product-contact components from beginning to end, greatly simplifying small-scale GMP manufacturing of multiple products. Secondly, we will report results of comparative testing with a range of modern ion exchange media (including resins, membrane adsorbers, monoliths and functionalized hydrogel formats). Thirdly, we will report the development and validation of novel quality control methods suitable for this process. The resulting process will allow the CBF to increase production yield and produce more vaccines that transfer more easily to larger facilities

Support needs in Carers of People with Parkinson’s from early to later stages: A qualitative study with 36 carers in 11 European countries

Background: Parkinson’s Disease (PD) is associated with considerable carer burden, but there has been little qualitative research on the support needs of carers of People with Parkinson’s (PwP). Methods: Semi-structured in-depth interviews with carers of PwP in 11 European countries. Results: Interviews with 36 carers of PwP were analysed. At the time of diagnosis, carers often felt that they had a role in helping get a diagnosis and then in dealing with the impact of the diagnosis on the family. Information on medication was seen as particularly important for carers, and many of the carers that their informational needs differed from that of the PwPs. Many of the carers also felt that they needed to be present at all appointments to request referrals or ask for medication changes. Carers of those in the later stages of the disease often reported feeling isolated and not having any time for themselves. Conclusions: The involvement of carers should be addressed more actively in the management of Parkinson’s

Assessing Boreal Peat Fire Severity and Vulnerability of Peatlands to Early Season Wildland Fire

Globally peatlands store large amounts of carbon belowground with 80% distributed in boreal regions of the northern hemisphere. Climate warming and drying of the boreal region has been documented as affecting fire regimes, with increased fire frequency, severity and extent. While much research is dedicated to assessing changes in boreal uplands, few research efforts are focused on the vulnerability of boreal peatlands to wildfire. In this case study, an integration of field data collection, land cover mapping of peatland types and Landsat-based fire severity mapping was conducted for four early season (May to mid-June) wildfires where peatlands are abundant in northeastern Alberta Canada. The goal was to better understand if peatlands burn more or less preferentially than uplands in fires and how severely the organic soil layers (peat) of different peatland ecotypes burn. The focus was on early season wildfires because they dominated the research area in the decade of study. To do this, a novel Landsat-5 metric was developed to retrieve fire severity of the organic surface layer. Spatial comparisons and statistical analysis showed that proportionally bogs are more likely to burn in early season Alberta wildfires than other ecosystem types, even fire-prone upland conifer. Although for a small sample, we found that when fire weather conditions for the duff layers are severe, the fens of this study appear to become more susceptible to burning. In addition, overall bogs experienced greater severity of burn to the peat layers than fens. Due to the small sample size of peat loss from fire in uplands and limited geographic area of this case study, we were unable to assess if bogs are burning more severely than uplands. Further analysis and Landsat algorithm development for organic soil fire severity in peatlands and uplands are needed to more fully understand trends in belowground consumption for wildfires of all seasons and boreal ecotypes

The mutation rate of mycobacterial repetitive unit loci in strains of M. tuberculosis from cynomolgus macaque infection

Background: Mycobacterial interspersed repetitive units (MIRUs) are minisatellites within the Mycobacterium tuberculosis (Mtb) genome. Copy number variation (CNV) in MIRU loci is used for epidemiological typing, making the rate of variation important for tracking the transmission of Mtb strains. In this study, we developed and assessed a whole-genome sequencing (WGS) approach to detect MIRU CNV in Mtb. We applied this methodology to a panel of Mtb strains isolated from the macaque model of tuberculosis (TB), the animal model that best mimics human disease. From these data, we have estimated the rate of MIRU variation in the host environment, providing a benchmark rate for future epidemiologic work. Results: We assessed variation at the 24 MIRU loci used for typing in a set of Mtb strains isolated from infected cynomolgus macaques. We previously performed WGS of these strains and here have applied both read depth (RD) and paired-end mapping (PEM) metrics to identify putative copy number variants. To assess the relative power of these approaches, all MIRU loci were resequenced using Sanger sequencing. We detected two insertion/deletion events both of which could be identified as candidates by PEM criteria. With these data, we estimate a MIRU mutation rate of 2.70 × 10-03 (95% CI: 3.30 × 10-04- 9.80 × 10-03) per locus, per year. Conclusion: Our results represent the first experimental estimate of the MIRU mutation rate in Mtb. This rate is comparable to the highest previous estimates gathered from epidemiologic data and meta-analyses. Our findings allow for a more rigorous interpretation of data gathered from MIRU typing

Silk from Crickets: A New Twist on Spinning

Raspy crickets (Orthoptera: Gryllacrididae) are unique among the orthopterans in producing silk, which is used to build shelters. This work studied the material composition and the fabrication of cricket silk for the first time. We examined silk-webs produced in captivity, which comprised cylindrical fibers and flat films. Spectra obtained from micro-Raman experiments indicated that the silk is composed of protein, primarily in a beta-sheet conformation, and that fibers and films are almost identical in terms of amino acid composition and secondary structure. The primary sequences of four silk proteins were identified through a mass spectrometry/cDNA library approach. The most abundant silk protein was large in size (300 and 220 kDa variants), rich in alanine, glycine and serine, and contained repetitive sequence motifs; these are features which are shared with several known beta-sheet forming silk proteins. Convergent evolution at the molecular level contrasts with development by crickets of a novel mechanism for silk fabrication. After secretion of cricket silk proteins by the labial glands they are fabricated into mature silk by the labium-hypopharynx, which is modified to allow the controlled formation of either fibers or films. Protein folding into beta-sheet structure during silk fabrication is not driven by shear forces, as is reported for other silks

The subjective experience of Parkinson's disease: a qualitative study in 60 people with mild to moderate Parkinson's in 11 European countries

Objective: To describe the experience of being diagnosed and living with mild to moderate Parkinson’s disease (PD). Method: Semi-structured in-depth interviews with people with Parkinson’s (PwP) in 11 European countries. Results: Interviews with 60 PwP (52% male) with a mean age of 63 (SD 8.1) years and a disease duration of 9.6 (SD 6.9) years were analysed. PwP often delayed help-seeking due to lack of awareness of symptoms, and there was sometimes a delay in specialist referral. The diagnosis typically came as a “shock”, making PwP unable to absorb all the information, but having a diagnosis for the symptoms was sometimes described as a “relief”. Prompt referral to a specialist, a clear and sensitively communicated diagnosis with reassurance about life expectancy, and a follow-up appointment with a PD nurse or other health care professionals a short interval after diagnosis were all positively viewed. Many reported worries and negative experiences with medications and wished for more time and information before initiating these. Reactions from family, friends, and work colleagues when communicating the diagnosis were typically positive. During ongoing care, longer appointments with specialists and provision of information from health care professionals, patient organisations, and self-help groups were considered important to many PwPs and helped them feel as if they could “take control” and manage their disease more effectively. Conclusions: Taking into account these findings has the potential to improve the experiences of PwP through improved communication, tailoring of appointments and information provision including self-help approaches. ? Introduction The impact of Parkinson’s disease (PD) on patients health-related quality of life has been studied extensively, demonstrating that all aspects of physical and emotional functioning can be affected in PD even at the earliest stages of the disease (Schrag et al., 2000). Management of PD aims at improving quality of life in people with Parkinson’s (PwP) using pharmacological, surgical and non-pharmacological strategies (Ferreira, et al. 2013). In order to improve quality of life in PwP, research has primarily focussed on quantitative assessments of motor and non-motor symptoms to optimise their medical treatment and thereby PwP’ wellbeing (Nicoletti et al., 2017). However, relatively little is known on the experience of being diagnosed with and living with PD from the point of view of PwP. This is particularly relevant when advising health care providers and clinicians on the non-medical aspects of managing PwP in current health care systems. We here report the results of a qualitative study in 60 individuals with a diagnosis of PD from 11 European countries on their experiences of being diagnosed and living with this disorder. Methods In 2014 and 2015, a qualitative research study was conducted as part of the “My PD Journey” project by the European Parkinson’s Disease Association (EPDA). Semi-structured interviews on the experiences of being diagnosed and living with PD were conducted with people with Parkinson’s (PwP) in 11 countries. Principles of Grounded Theory were used to guide the sampling, data collection, and data analysis (Glaser & Strauss, 2009)

Protein Complexes and Proteolytic Activation of the Cell Wall Hydrolase RipA Regulate Septal Resolution in Mycobacteria

Peptidoglycan hydrolases are a double-edged sword. They are required for normal cell division, but when dysregulated can become autolysins lethal to bacteria. How bacteria ensure that peptidoglycan hydrolases function only in the correct spatial and temporal context remains largely unknown. Here, we demonstrate that dysregulation converts the essential mycobacterial peptidoglycan hydrolase RipA to an autolysin that compromises cellular structural integrity. We find that mycobacteria control RipA activity through two interconnected levels of regulation in vivo—protein interactions coordinate PG hydrolysis, while proteolysis is necessary for RipA enzymatic activity. Dysregulation of RipA protein complexes by treatment with a peptidoglycan synthase inhibitor leads to excessive RipA activity and impairment of correct morphology. Furthermore, expression of a RipA dominant negative mutant or of differentially processed RipA homologues reveals that RipA is produced as a zymogen, requiring proteolytic processing for activity. The amount of RipA processing differs between fast-growing and slow-growing mycobacteria and correlates with the requirement for peptidoglycan hydrolase activity in these species. Together, the complex picture of RipA regulation is a part of a growing paradigm for careful control of cell wall hydrolysis by bacteria during growth, and may represent a novel target for chemotherapy development