\u3ci\u3eClinostomum poteae\u3c/i\u3e n. sp. (Digenea: Clinostomidae), in the trachea of a double-crested cormorant \u3ci\u3ePhalacrocorax auritus\u3c/i\u3e Lesson, 1831 and molecular data linking the life-cycle stages of \u3ci\u3eClinostomum album\u3c/i\u3e Rosser, Alberson, Woodyard, Cunningham, Pote & Griffin, 2017 in Mississippi, USA

Clinostomum spp. (Digenea: Clinostomidae) are a group of trematodes commonly found in the buccal cavity and oesophagus of a variety of piscivorous birds. The metacercariae, colloquially known as ‘‘yellow grubs,’’ have been reported from a diverse group of freshwater fishes worldwide. In the catfish farming region of the southeastern USA, piscivorous birds present a continuous challenge for aquaculturists in the form of fish depredation and the introduction of trematodes into these static, earthen pond systems. Clinostomum spp. are commonly encountered in farmraised catfish. While generally considered pests of minimal importance, heavy infections can result in unmarketable fillets. Of the piscivorous birds that frequent catfish aquaculture operations in the southeastern US, the double-crested cormorant (Phalacrocorax auritus Lesson) is one of the most damaging, although reports of Clinostomum spp. from P. auritus are limited. In this study, adult trematodes morphologically consistent with Clinostomum sp. were found in the trachea of a double-crested cormorant captured in Lowndes Co., Mississippi, USA. These specimens differed from other recognised Clinostomum spp. in several key morphological characters. Moreover, sequence data of mitochondrial cytochrome c oxidase subunit 1 gene (cox1), nicotinamide adenine dinucleotide dehydrogenase subunit 1 gene (nad1) and ribosomal internal transcribed spacer (ITS) regions did not match any known Clinostomum sp. for which sequence data are available. While genetically similar to C. marginatum and C. album Rosser, Alberson, Woodyard, Cunningham, Pote & Griffin, 2017 reported from the great egret Ardea alba L. in Mississippi, these adult clinostomids were larger in size and limited to the trachea, whereas both C. marginatum Rudolphi, 1819 and C. album are found in the oral cavity and esophagus. Given these distinct morphological and molecular characters we propose a new member of the genus, known hereafter as Clinostomum poteae n. sp. Additionally, larval stages in the life-cycle of C. album are morphologically and molecularly identified for the first time from ramshorn snails Planorbella trivolvis Say and fathead minnows Pimephales promelas Rafinesque

Experimental Elucidation of the Life Cycle of \u3ci\u3eDrepanocephalus Spathans\u3c/i\u3e (Digenea: Echinostomatidae) with Notes on the Morphological Plasticity of \u3ci\u3eD. Spathans\u3c/i\u3e in the United States

The echinostomatid Drepanocephalus spathans (syn. Drepanocephalus auritus) parasitizes the doublecrested cormorant Phalacrocorax auritus. In North America, the marsh rams-horn snail Planorbella trivolvis and ghost rams-horn snail Biomphalaria havanensis serve as snail intermediate hosts, both of which inhabit catfish aquaculture ponds in the southeastern United States. Studies have demonstrated D. spathans exposure can be lethal to juvenile channel catfish Ictalurus punctatus. Two studies were undertaken to elucidate the life cycle of D. spathans to establish a developmental time line. In both studies, D. spathans cercariae collected from naturally infected P. trivolvis individuals were used to infect channel catfish fingerlings, which were then fed to double-crested cormorants (DCCOs) that had been pharmaceutically dewormed. In study 1, laboratory-reared P. trivolvis and B. havanensis individuals were placed in aviary ponds with experimentally infected DCCO and examined bi-weekly for release of cercariae. Trematode eggs were observed in the feces of exposed birds 3 days post-infection. Birds were sacrificed 18 days post-exposure (dpe), and gravid adults morphologically and molecularly consistent with D. spathans were recovered. Snails from the aviary pond were observed shedding D. spathans cercariae 18–54 dpe. In study 2, trematode eggs were observed in the feces of exposed DCCOs beginning 8 dpe. Once eggs were observed, birds were allowed to defecate into clean tanks containing naı¨ve laboratory-reared P. trivolvis individuals. Additionally, eggs from experimental DCCO feces were recovered by sedimentation and placed in an aquarium housing laboratory-reared P. trivolvis individuals. Birds in study 2 were sacrificed after 60 days, and gravid D. spathans specimens were recovered. Snails from the experimental DCCO tanks shed D. spathans cercariae 89–97 dpe. Lastly, trematode eggs were isolated and observed for the hatching of miracidia, which emerged on average after 16 days at ambient temperatures. No D. spathans adults were observed in control birds fed non-parasitized fish. This is the first experimental confirmation of the D. spathans life cycle, resolving previously unknown developmental time lines. In addition, the effects of fixation on adult trematode morphology were assessed, clarifying reports of pronounced morphological plasticity for D. spathans

Systematic review of economic evaluations and cost analyses of guideline implementation strategies

Objectives To appraise the quality of economic studies undertaken as part of evaluations of guideline implementation strategies; determine their resources use; and recommend methods to improve future studies. Methods Systematic review of economic studies undertaken alongside robust study designs of clinical guideline implementation strategies published (1966-1998). Studies assessed against the BMJ economic evaluations guidelines for each stage of the guideline process (guideline development, implementation and treatment). Results 235 studies were identified, 63 reported some information on cost. Only 3 studies provided evidence that their guideline was effective and efficient. 38 reported the treatment costs only, 12 implementation and treatment costs, 11 implementation costs alone, and two guideline development, implementation and treatment costs. No study gave reasonably complete information on costs. Conclusions Very few satisfactory economic evaluations of guideline implementation strategies have been performed. Current evaluations have numerous methodological defects and rarely consider all relevant costs and benefits. Future evaluations should focus on evaluating the implementation of evidence based guidelines. Keywords: Cost-effectiveness analysis, physician (or health care professional) behaviour, practice guidelines, quality improvement, systematic review.Peer reviewedAuthor versio

Physical activity and exercise outcomes in Huntington Disease (PACE-HD): Protocol for a 12-Month trial within cohort evaluation of a physical activity intervention in people with Huntington Disease

Background Exercise is emerging as an important aspect in the management of disease-related symptoms and functional decline in people with Huntington disease (HD). Long-term evaluation of physical activity and exercise participation in HD has yet to be undertaken. Objective The objective is to investigate the feasibility of a nested randomized controlled trial (RCT) alongside a longitudinal observational study of physical activity and exercise outcomes in people with HD. Design This will be a 12-month longitudinal observational study (n = 120) with a nested evaluation of a physical activity intervention (n = 30) compared with usual activity (n = 30) using a “trial within a cohort” design. Setting The study will take place in HD specialist clinics in Germany, Spain, and the United States, with intervention delivery in community settings. Participants The participants will have early-mid–stage HD and be participating in the Enroll-HD study. Intervention This will be a 12-month physical activity behavioral change intervention, delivered by physical therapists in 18 sessions, targeting uptake of aerobic exercise and increased physical activity. Measurements All participants (n = 120) will complete Enroll-HD assessments (motor, cognitive, behavioral, and quality of life) at baseline and at 12 months. Additional Physical ACtivity and Exercise Outcomes in Huntington Disease (PACE-HD) assessments include fitness (predicted maximal oxygen uptake [V  o2max]), self-reported and quantitative measures of physical activity, disease-specific symptoms, and walking endurance. RCT participants (n = 60) will complete an additional battery of quantitative motor assessments and a 6-month interim assessment. Enroll-HD data will be linked to PACE-HD physical activity and fitness data. Limitations The limitations include that the embedded RCT is open, and assessors at RCT sites are not blinded to participant allocation. Conclusion PACE-HD will enable determination of the feasibility of long-term physical activity interventions in people with HD. The novel “trial within a cohort” design and incorporation of data linkage have potential to reduce participant burden. This design could be applied to other neurological diseases and movement disorders where recruitment and retention are challenging

Role of CD14+ monocyte-derived oxidised mitochondrial DNA in the inflammatory interferon type 1 signature in juvenile dermatomyositis

OBJECTIVES: To define the host mechanisms contributing to the pathological interferon (IFN) type 1 signature in Juvenile dermatomyositis (JDM). METHODS: RNA-sequencing was performed on CD4+, CD8+, CD14+ and CD19+ cells sorted from pretreatment and on-treatment JDM (pretreatment n=10, on-treatment n=11) and age/sex-matched child healthy-control (CHC n=4) peripheral blood mononuclear cell (PBMC). Mitochondrial morphology and superoxide were assessed by fluorescence microscopy, cellular metabolism by 13C glucose uptake assays, and oxidised mitochondrial DNA (oxmtDNA) content by dot-blot. Healthy-control PBMC and JDM pretreatment PBMC were cultured with IFN-α, oxmtDNA, cGAS-inhibitor, TLR-9 antagonist and/or n-acetyl cysteine (NAC). IFN-stimulated gene (ISGs) expression was measured by qPCR. Total numbers of patient and controls for functional experiments, JDM n=82, total CHC n=35. RESULTS: Dysregulated mitochondrial-associated gene expression correlated with increased ISG expression in JDM CD14+ monocytes. Altered mitochondrial-associated gene expression was paralleled by altered mitochondrial biology, including 'megamitochondria', cellular metabolism and a decrease in gene expression of superoxide dismutase (SOD)1. This was associated with enhanced production of oxidised mitochondrial (oxmt)DNA. OxmtDNA induced ISG expression in healthy PBMC, which was blocked by targeting oxidative stress and intracellular nucleic acid sensing pathways. Complementary experiments showed that, under in vitro experimental conditions, targeting these pathways via the antioxidant drug NAC, TLR9 antagonist and to a lesser extent cGAS-inhibitor, suppressed ISG expression in pretreatment JDM PBMC. CONCLUSIONS: These results describe a novel pathway where altered mitochondrial biology in JDM CD14+ monocytes lead to oxmtDNA production and stimulates ISG expression. Targeting this pathway has therapeutical potential in JDM and other IFN type 1-driven autoimmune diseases

Huntington’s disease age at motor onset is modified by the tandem hexamer repeat in TCERG1

Huntington’s disease is caused by an expanded CAG tract in HTT. The length of the CAG tract accounts for over half the variance in age at onset of disease, and is influenced by other genetic factors, mostly implicating the DNA maintenance machinery. We examined a single nucleotide variant, rs79727797, on chromosome 5 in the TCERG1 gene, previously reported to be associated with Huntington’s disease and a quasi-tandem repeat (QTR) hexamer in exon 4 of TCERG1 with a central pure repeat. We developed a method for calling perfect and imperfect repeats from exome-sequencing data, and tested association between the QTR in TCERG1 and residual age at motor onset (after correcting for the effects of CAG length in the HTT gene) in 610 individuals with Huntington’s disease via regression analysis. We found a significant association between age at onset and the sum of the repeat lengths from both alleles of the QTR (p = 2.1 × 10−9), with each added repeat hexamer reducing age at onset by one year (95% confidence interval [0.7, 1.4]). This association explained that previously observed with rs79727797. The association with age at onset in the genome-wide association study is due to a QTR hexamer in TCERG1, translated to a glutamine/alanine tract in the protein. We could not distinguish whether this was due to cis-effects of the hexamer repeat on gene expression or of the encoded glutamine/alanine tract in the protein. These results motivate further study of the mechanisms by which TCERG1 modifies onset of HD

Timing and impact of psychiatric, cognitive, and motor abnormalities in Huntington disease

Objective To assess the prevalence, timing and functional impact of psychiatric, cognitive and motor abnormalities in Huntington’s disease (HD) gene carriers, we analysed retrospective clinical data from individuals with manifest HD. Methods Clinical features of HD patients were analysed for 6316 individuals in the European REGISTRY study from 161 sites across 17 countries. Data came from clinical history and the patient-completed Clinical Characteristics Questionnaire that assessed eight symptoms: motor, cognitive, apathy, depression, perseverative/obsessive behavior, irritability, violent/aggressive behavior, and psychosis. Multiple logistic regression was used to analyse relationships between symptoms and functional outcomes. Results The initial manifestation of HD is increasingly likely to be motor, and less likely to be psychiatric, as age at presentation increases, and is independent of pathogenic CAG repeat length. The Clinical Characteristics Questionnaire captures data on non-motor symptom prevalence that correlate specifically with validated clinical measures. Psychiatric and cognitive symptoms are common in HD gene carriers, with earlier onsets associated with longer CAG repeats. 42.4% of HD patients reported at least one psychiatric or cognitive symptom before motor symptoms, with depression most common. Each non-motor symptom was associated with significantly reduced total functional capacity scores. Conclusions Psychiatric and cognitive symptoms are common and functionally debilitating in HD gene carriers. They require recognition and targeting with clinical outcome measures and treatments. However, as it is impossible to distinguish confidently between non-motor symptoms arising from HD and primary psychiatric disorders, particularly in younger pre-manifest patients, non-motor symptoms should not be used to make a clinical diagnosis of HD

The onset and prevalence of motor and psychiatric symptoms in Huntington’s disease

Background Huntington’s disease is characterised by a range of motor, psychiatric and cognitive symptoms. These present in different combinations through the disease course and impact on daily life and functioning. Huntington’s disease is caused by a dominant CAG repeat expansion in the HTT gene, and longer repeats are associated with earlier onset of motor symptoms. Objectives To investigate the onset, prevalence and functional impact of motor and psychiatric symptoms of Huntington’s disease. Methods We analysed clinical phenotype data from the European REGISTRY study for 6316 individuals with manifest Huntington’s disease. Onset and prevalence data for motor and psychiatric symptoms were extracted from the clinical history part of REGISTRY and the detailed Clinical Characteristics Questionnaire. Generalised linear models were constructed to assess relationships between symptoms and functional outcomes. Results As age at first presentation of Huntington’s disease increases, the likelihood that the initial presenting symptom is motor also increases. This is not associated with pathogenic CAG repeat length. At a population level there were conserved relationships between symptoms across different repeat lengths, with depression often occurring early followed by motor and then cognitive symptoms. There were significant relationships between all individual psychiatric and cognitive symptoms and reduced functional capacity. Conclusions There are conserved patterns of symptoms in HD that can be quantified. Psychiatric and behavioural symptoms significantly impair daily functioning and should be considered part of the disease trajectory at any age

Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study

Background Ambulance services need to identify and prioritise patients with sepsis for early hospital assessment. We aimed to determine the accuracy of early warning scores alongside paramedic diagnostic impression to identify sepsis that required urgent treatment. Methods We undertook a retrospective diagnostic cohort study involving adult emergency medical cases transported to Sheffield Teaching Hospitals ED by Yorkshire Ambulance Service in 2019. We used routine ambulance service data to calculate 21 early warning scores and categorise paramedic diagnostic impressions as sepsis, infection, non-specific presentation or other presentation. We linked cases to hospital records and identified those meeting the sepsis-3 definition who received urgent hospital treatment for sepsis (reference standard). Analysis determined the accuracy of strategies that combined early warning scores at varying thresholds for positivity with paramedic diagnostic impression. Results We linked 12 870/24 955 (51.6%) cases and identified 348/12 870 (2.7%) with a positive reference standard. None of the strategies provided sensitivity greater than 0.80 with positive predictive value greater than 0.15. The area under the receiver operating characteristic curve for the National Early Warning Score, version 2 (NEWS2) applied to patients with a diagnostic impression of sepsis or infection was 0.756 (95% CI 0.729, 0.783). No other early warning score provided clearly superior accuracy to NEWS2. Paramedic impression of sepsis or infection had sensitivity of 0.572 (0.519, 0.623) and positive predictive value of 0.156 (0.137, 0.176). NEWS2 thresholds of >4, >6 and >8 applied to patients with a diagnostic impression of sepsis or infection, respectively, provided sensitivities and positive predictive values of 0.522 (0.469, 0.574) and 0.216 (0.189, 0.245), 0.447 (0.395, 0.499) and 0.274 (0.239, 0.313), and 0.314 (0.268, 0.365) and 0.333 (0.284, 0.386). Conclusion No strategy is ideal but using NEWS2 alongside paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2