Πέμπτη, 5 Ιανουαρίου 2017

Airway Management With a Stereotactic Headframe In Situ-A Mannequin Study.

Background: Stereotactic headframe-based imaging is often needed for target localization during surgery for insertion of deep brain stimulators. A major concern during this surgery is the need for emergency airway management while an awake or sedated patient is in the stereotactic headframe. The aim of our study was to determine the ease of emergency airway management with a stereotactic headframe in situ. Materials and Methods: We conducted an observational study using a mannequin. A Leksell stereotactic headframe was placed on a mannequin in the operating room and the frame was fixed to the operating room table. Anesthesia personnel were asked to insert a #4 laryngeal mask and then to intubate the mannequin, using both direct (DL) and video laryngoscopy (VL). In addition, participants were asked to perform the same airway techniques in the mannequin without the headframe. Data were analyzed for time taken for airway management using different devices with and without the headframe. In addition, we compared the time taken to secure the airway between different participant groups. Results: Thirty anesthesia personnel (7 residents, 12 fellows, and 11 consultants) participated in the study. With the headframe in situ, 97% of participants were able to insert a laryngeal mask on their first attempt; 93% and 97% of participants were able to intubate the mannequin using DL and VL respectively on their first attempt. Without the stereotactic headframe, all participants were able to insert the laryngeal mask and intubate on the first attempt. The average time taken to insert a laryngeal mask and intubate the mannequin using DL and VL with the headframe in situ was 39.3, 58.6, and 54.8 seconds, respectively. Conclusions: Our study showed that both laryngeal mask insertion and tracheal intubation can be performed with a stereotactic headframe in situ. A laryngeal mask is the quickest airway device to insert and can be inserted while the mannequin is in the standard surgical position. Further study is needed to validate the results in patients. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved

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Hemodynamic monitoring in thoracic surgical patients.

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Purpose of review: This article reviews the technology and clinical data describing hemodynamic monitoring devices available to anesthesiologists and intensivists caring for patients undergoing thoracic surgical procedures, so that they may better utilize available technology to improve outcomes in this high-risk surgical population. Recent findings: Noninvasive stroke volume monitors are based on several different technology platforms, all of which have distinct performance characteristics. Strong clinical outcomes data support the use of these devices in patients undergoing major surgical procedures although these studies generally do not target thoracic surgical procedures specifically. The predictive ability of respiratory variation (for measuring fluid responsiveness) is controversial in both one lung and low tidal volume ventilation. Extravascular lung water measurements are well validated, predict postoperative lung function, but require the use of transpulmonary thermodilution. Summary: Technology that has been shown to improve clinical outcomes in major surgical procedures is likely applicable to patients undergoing thoracic surgical procedures; however, several unique features of these procedures limit or modify the way in which these devices can be used. Understanding the scientific basis of these devices is the key to using them effectively. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Multilocus Analysis Reveals Three Candidate Genes for Chinese Migraine Susceptibility

Abstract

Several genome-wide association studies (GWASs) in Caucasian populations have identified 12 loci that are significantly associated with migraine. More evidence suggests that serotonin receptors are also involved in migraine pathophysiology. In the present study, a case–control study was conducted in a cohort of 581 migraine cases and 533 ethnically matched controls among a Chinese population. Eighteen polymorphisms from serotonin receptors and GWASs were selected, and genotyping was performed using a Sequenom MALDI-TOF mass spectrometry iPLEX platform. The genotypic and allelic distributions of MEF2D rs2274316 and ASTN2 rs6478241 were significantly different between migraine patients and controls. Univariate and multivariate analysis revealed significant associations of polymorphisms in the MEF2D and ASTN2 genes with migraine susceptibility. MEF2D, PRDM16 and ASTN2 were also found to be associated with migraine without aura (MO) and migraine with family history. And MEF2D and ASTN2 also served as genetic risk factors for the migraine without family history. The Generalized Multifactor-Dimensionality Reduction analysis identified that MEF2D and HTR2E constituted the two-factor interaction model. Our study suggests that the MEF2D, PRDM16 and ASTN2 genes from GWAS are associated with migraine susceptibility, especially MO, among Chinese patients. It appears that there is no association with serotonin receptor related-genes.

Thumbnail image of graphical abstract

Graphical Abstract

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The Microscale Distribution and Dynamic Surface Tension of Pulmonary Surfactant Normalizes the Recruitment of Asymmetric Bifurcating Airways.

We investigate the influence of bifurcation geometry, asymmetry of daughter airways, surfactant distribution and physicochemical properties on the uniformity of airway recruitment of asymmetric bifurcating airways. To do so, we developed micro-fluidic idealized in vitro models of bifurcating airways, through which we can independently evaluate the impact of carina location, and the daughter airway width and length. We explore the uniformity of recruitment and its relationship to the dynamic surface tension of the lining fluid, and relate this behavior to the hydraulic and capillary pressure drops (PHyd and PCap, respectively). These studies demonstrate the extraordinary importance of PCap in stabilizing reopening, even in highly asymmetric systems. The dynamic surface tension of pulmonary surfactant is integral to this stability because it modulates PCap in a velocity-dependent manner. Furthermore, the surfactant distribution at the propagating interface can have a very large influence on recruitment stability by focusing surfactant preferentially to specific daughter airways. This implies that modification of the surfactant distribution through novel modes of ventilation could be useful in inducing uniformly recruited lungs, aiding in gas exchange and reducing ventilator-induced lung injury (VILI).



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Susceptibility To High Altitude Pulmonary Edema Is Associated With A More Uniform Distribution Of Regional Specific Ventilation

High altitude pulmonary edema (HAPE) is a potentially fatal condition affecting high altitude sojourners. The biggest predictor of HAPE development is a history of prior HAPE. Magnetic resonance imaging (MRI) shows HAPE-susceptible, with a history of HAPE, but not HAPE-resistant (a history of repeated ascents without illness) individuals develop greater heterogeneity of regional pulmonary perfusion breathing hypoxic gas (O2=12.5%), consistent with uneven hypoxic pulmonary vasoconstriction (HPV). Why HPV is uneven in HAPE-susceptibles is unknown, but may arise from regionally heterogeneous ventilation resulting in an uneven stimulus to HPV. We tested the hypothesis that ventilation is more heterogeneous in HAPE-susceptible subjects (n=6) compared to HAPE-resistant controls (n=7). MRI Specific Ventilation Imaging (SVI), was used to measure regional specific ventilation and the relative dispersion (SD/mean) of SVI used to quantify baseline heterogeneity. Ventilation heterogeneity from conductive and respiratory airways was measured in normoxia and hypoxia (O2=12.5%) using multiple breath washout and heterogeneity quantified from the indices Scond and Sacin, respectively. Contrary to our hypothesis, HAPE-susceptibles had significantly lower relative dispersion of specific ventilation than the HAPE-resistant controls (Susceptible=1.33±0.67, Resistant=2.36±0.98, p=0.05) and Sacin tended to be more uniform (Susceptible=0.085±0.009, Resistant=0.113±0.030, p=0.07). Scond was not significantly different between groups (Susceptible=0.019±0.007, Resistant=0.020±0.004, p=0.67). Sacin and Scond did not change significantly in hypoxia (p=0.56, 0.19, respectively). In conclusion, ventilation heterogeneity does not change with short-term hypoxia irrespective of HAPE susceptibility and lesser rather than greater ventilation heterogeneity is observed in HAPE-susceptible subjects. This suggests the basis for uneven HPV in HAPE involves vascular phenomena.



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CONTRACTILE EFFICIENCY OF DYSTROPHIC MDX MOUSE MUSCLE: IN VIVO AND EX VIVO ASSESSMENT OF ADAPTATION TO EXERCISE OF FUNCTIONAL END-POINTS

Progressive weakness is a typical feature of Duchenne muscular dystrophy (DMD) patients and is exacerbated in the benign mdx mouse model by in vivo treadmill exercise. We hypothesized a different threshold for functional adaptation of mdx muscles in response to the duration of the exercise protocol. In vivo weakness was confirmed by grip strength after 4, 8 and 12 weeks of exercise in mdx mice. Torque measurements revealed that exercise-related weakness in mdx mice correlated with the duration of the protocol, while wild-type (wt) mice were stronger. Twitch and tetanic forces of isolated diaphragm and extensor digitorum longus (EDL) muscles, were lower in mdx compared to wt mice. In mdx, both muscle types exhibited greater weakness after a single exercise bout, but only in EDL after a long exercise protocol. As opposite to wt muscles, mdx EDL ones did not show any exercise-induced adaptations against eccentric contraction force drop. qRT-PCR analysis confirmed the maladaptation of genes involved in metabolic and structural remodeling, while damage-related genes remained significantly upregulated and angiogenesis impaired. Phosphorylated AMP kinase level increased only in exercised wt muscle. The severe histopathology and the high levels of muscular TGF-β1 and of plasma matrix metalloproteinase-9 confirmed the persistence of muscle damage in mdx mice. Then, dystrophic muscles showed a partial degree of functional adaptation to chronic exercise, although not sufficient to overcome weakness nor signs of damage. The improved understanding of the complex mechanisms underlying maladaptation of dystrophic muscle paves the way to a better managment of DMD patients.



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Blood flow regulation and oxygen uptake during high intensity forearm exercise

The vascular strain is very high during heavy handgrip exercise, but the intensity and kinetics to reach peak blood flow, and peak oxygen uptake, are uncertain. We included 9 young (25±2yr) healthy males to evaluate blood flow and oxygen uptake responses during continuous dynamic handgrip exercise with increasing intensity. Blood flow was measured using Doppler-ultrasound and venous blood was drawn from a deep forearm vein to determine arteriovenous oxygen difference (a-vO2diff) during 6-minutes bouts of 60, 80 and 100% of maximal work rate (WRmax), respectively. Blood flow and oxygen uptake increased (p<0.05) from 60%WRmax (557±177(SD) mL•min-1; 56.0±21.6 mL•min-1) to 80%WRmax (679±190 mL•min-1; 70.6±24.8 mL•min-1), but no change was seen from 80%WRmax to 100%WRmax. Blood velocity (49.5±11.5 cm•sec-1 to 58.1±11.6 cm•sec-1) and brachial diameter (0.49±0.05cm to 0.50±0.06 cm) showed concomitant increases (p<0.05) with blood flow from 60% to 80%WRmax, while no differences were observed in a-vO2diff. Shear rate also increased (p<0.05) from 60% (822±196 s-1) to 80% (951±234 s-1) of WRmax. The mean response time (MRT) was slower (p<0.05) for blood flow (60%WRmax:50±22s; 80%WRmax:51±20s; 100%WRmax:51±23s) than a-vO2diff (60%WRmax:29±9s; 80%WRmax:29±5s; 100%WRmax:20±5s), but not different from oxygen uptake (60%WRmax:44±25s; 80%WRmax:43±14s; 100%WRmax:41±32s). No differences were observed in MRT for blood flow or oxygen uptake with increased exercise intensity. In conclusion, when approaching maximal intensity, oxygen uptake appeared to reach a critical level at ~80% of WRmax and be regulated by blood flow. This implies that high, but not maximal, exercise intensity may be an optimal stimulus for shear stress-induced small muscle mass training adaptations.



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DNA Methylation Assessment from Human Slow- and Fast-Twitch Skeletal Muscle Fibers

A new application of the Reduced Representation Bisulfite Sequencing method was developed using low-DNA input to investigate the epigenetic profile of human slow- and fast-twitch skeletal muscle fibers. Successful library construction was completed with as little as 15 ng of DNA and high quality sequencing data were obtained with 32 ng of DNA. Analysis identified 143,160 differentially methylated CpG-sites across 14,046 genes. In both fiber types, selected genes predominantly expressed in slow or fast fibers were hypomethylated, which was supported by the RNA-Seq analysis. These are the first fiber-type specific methylation data from human skeletal muscle and provide a unique platform for future research.



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A new method to evaluate macaque health using exhaled breath: A case study of M. tuberculosis in a BSL-3 setting

Breath is hypothesized to contain clinically relevant information, useful for the diagnosis and monitoring of disease, as well as understanding underlying pathogenesis. Non-human primates, such as the cynomolgus macaque, serve as an important model for the study of human disease, including over 70 different human infections. In this feasibility study, exhaled breath was successfully collected in less than five minutes under Biosafety Level 3 conditions from five anesthetized, intubated cynomolgus and rhesus macaques, before and after lung infection with M. tuberculosis. The breath was subsequently analyzed using comprehensive two-dimensional gas chromatography coupled to mass spectrometry . A total of 384 macaque breath features were detected, with hydrocarbons being the most abundant. We provide putative identification for 19 breath molecules and report on overlap between the identified macaque breath compounds and those identified in previous human studies.



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The effects of Ca2+ buffers on cytosolic Ca2+ signalling

Abstract

Ca2+ is one of the most important and universal intracellular signalling agents, controlling a multitude of vitally important cellular processes.

This article is protected by copyright. All rights reserved



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Reproducibility of sagittal radiographic parameters in adolescent idiopathic scoliosis – a guide to reference values using serial imaging

Knowledge of sagittal radiographical parameters in AIS patients has not yet caught up with our understanding of their roles in patients with adult spinal deformity. It is likely that more emphasis will be placed in restoring sagittal parameters for AIS patients in the future. Therefore we need to understand how these parameters may vary in AIS to facilitate management plans.

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The effectiveness of robotic-assisted gait training for paediatric gait disorders: systematic review

Robotic-assisted gait training (RAGT) affords an opportunity to increase walking practice with mechanical assistance from robotic devices, rather than therapists, where the child may not be able to generate a ...

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Quick Med Claims acquires Holdsworth Group EMS billing division

PITTSBURGH — Quick Med Claims, LLC (QMC) has announced the acquisition of The Holdsworth Group's Emergency Medical Billing Division based in Cromwell, CT. Holdsworth has provided outsourced billing and collections for a customer base comprised of public and private emergency medical services that provide ground ambulance services in their respective communities. The Holdsworth Group currently ...

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SnoRNAs are involved in the progression of ulcerative colitis and colorectal cancer

Emerging evidences indicate that small nucleolar RNAs (snoRNAs) are important regulatory molecules involved in various pathophysiological processes including inflammation and cancer. In the current study, we investigate whether snoRNAs dysregulate in colorectal cancer (CRC) and intestinal inflammation and contribute the pathogenesis of CRC.

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SnoRNAs are involved in the progression of ulcerative colitis and colorectal cancer

Emerging evidences indicate that small nucleolar RNAs (snoRNAs) are important regulatory molecules involved in various pathophysiological processes including inflammation and cancer. In the current study, we investigate whether snoRNAs dysregulate in colorectal cancer (CRC) and intestinal inflammation and contribute the pathogenesis of CRC.

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5 EMS compliance resolutions

By Amanda Ward

The beginning of a new calendar year or fiscal year is a time to reflect on all that we've accomplished in the past year and to set goals for the year to come. This year, resolve to finally implement a compliance program at your agency or jump start your current program.

Remember, the Affordable Care Act mandates that all health care providers have a compliance program in place. Even though the future of the ACA is uncertain, the government's efforts to combat health care fraud and abuse have yielded over $1.5 billion in savings. In other words, even if the law mandating compliance programs is repealed, the government is going to continue to look for Medicare fraud and abuse among health care providers. The best way to ensure your agency avoids trouble is to have an updated, effective compliance program.

While starting a compliance program can seem overwhelming, there are some small changes that can have a major impact on your agency's overall compliance. These five resolutions will get your started on the path to implementing or improving your compliance program.

1. Resolve to designate a compliance officer.

Having a designated compliance officer to operate and monitor the compliance program ensures that Medicare compliance is a top priority for your organization. The compliance officer should be a high-level individual within your agency who reports directly to your top management such as the chief, CEO or board of directors. The goal is to make sure that the top-decision makers have unfiltered, accurate information about the compliance risks affecting your agency.

The compliance officer should be responsible for staying current with Medicare rules and regulations, assessing the agency's risks, overseeing the compliance committee, conducting internal audits and communicating with staff members. While it's not realistic for most EMS agencies to have someone whose only responsibility is to be the compliance officer, ensure that your compliance officer has the time and resources to devote sufficient time to the role.

2. Resolve to conduct regular internal audits.

Internal claim reviews are the single best way to assess your agency's compliance risks. Your claim reviews should evaluate the entire claim submission process from call intake and dispatch through payment and collections. Regularly reviewing a sample of your claims provides you with a snapshot of the process so you can uncover deficiencies. A claim review allows you to determine if sufficient information is being obtained through call intake, if crew documentation paints a complete and accurate picture of the patient's condition and treatment, if proper billing and coding decisions are made and if reasonable collection efforts are being pursued.

3. Resolve to supplement your internal audits with an annual external audit.

Periodic external audits are important to supplement your agency's internal audits. Ideally, a qualified outside ambulance claim auditor will look at a sample of your claims on at least an annual basis. Some agencies have an external audit completed two to four times per year. Sometimes the same errors made during claim submission can be missed during internal audits, so external claim audits are a necessary confidence check to the internal auditing process.

Make sure your external auditor has an appropriate credential like Certified Ambulance Coder or Certified Ambulance Compliance Officer. If your external auditor is a law firm, you have the added bonus of the protections of the attorney-client privilege.

4. Resolve to refund overpayments promptly.

Regular claim reviews are also a proactive compliance activity to identify overpayments. In 2016, a new set of regulations took effect that require providers to refund Medicare overpayments within 60 days of being identified. If overpayments are not refunded within this time, they become violations of the False Claims Act, which multiplies the financial consequences significantly. Make sure you have a process in place that begins with payment posting and involves regular reviews to identify any potential overpayments and then to promptly refund overpayments according to your Medicare Administrative Contractor's refund process.

5. Resolve to check the OIG Exclusions Database monthly.

The OIG has the authority to exclude individuals and entities from participating in federal health care programs. This means if someone is excluded, then they can't provide care that is paid for by federal health care programs, submit claims to federal health care programs or own or manage an entity that participates in federal health care programs.

In other words, someone who has been excluded probably can't be involved with your agency. Employing someone who is excluded can carry a hefty price tag. If, for example, a field provider is excluded, every transport paid by a federal health care program that individual participated in while excluded is an overpayment that must be refunded.

While it's not required, the OIG recommends checking the Exclusions Database on a monthly basis. All staff members should be checked prior to hire and monthly thereafter. Prior to engaging with any vendor, you should also check the entity against the database. If an individual or entity is excluded, you should not hire the person or engage the entity for services. If you discover that a current employee or vendor is excluded, you should immediately remove them from any activities associated with federal health care programs and contact your legal counsel.

If compliance has been ignored or overlooked at your agency, this is the year to make a change. Resolve to make compliance a priority every year to help your agency avoid costly mistakes.



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6 actions to join EMS 3.0 transformation

The transformation to EMS 3.0 is expanding roles and opportunities for EMS systems. Five of the most common roles already being undertaken are nurse triage, post discharge follow-up care, chronic disease management, ambulance transport alternatives and payment alternatives. To begin preparing your EMS agency for the 3.0 transformation, here are six actions you should do immediately:

1. Read the book Mobile Integrated Healthcare: Approach to Implementation from Jones and Bartlett Learning. It provides an excellent overview of the steps toward EMS 3.0 you can take in your local community.

2. Visit the NAEMT MIH-CP Knowledge Center. It contains excellent resources that are updated regularly to help you learn about the transformation movement.

3. Attend the upcoming EMS Transformation Summit in Washington, D.C. This annual educational conference is specifically focused on the attributes of the 3.0 transformation.

4. Start talking to your local health care stakeholders. Find out what their concerns are and educate them on the ways your EMS agency can help them meet their Triple Aim goals.

5. Enroll in the IHI Open School program. This educational offering teaches you how to do quality improvement in health care. Yes, EMS is health care and the IHI Open School will arm you with the knowledge and skills to do transformation. NAEMT has full-tuition scholarships available as a member benefit for NAEMT members.

6. Enroll in the Academy of International Mobile Healthcare Integration (AIMHI) email news distribution list. AIMHI regularly sends out timely articles on the health care and EMS transformation. It is a great way to stay up to date on the changes that will affect you and your agency. To subscribe, send an email to MZavadsky@medstar911.org.



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6 actions to join EMS 3.0 transformation

The transformation to EMS 3.0 is expanding roles and opportunities for EMS systems. Five of the most common roles already being undertaken are nurse triage, post discharge follow-up care, chronic disease management, ambulance transport alternatives and payment alternatives. To begin preparing your EMS agency for the 3.0 transformation, here are six actions you should do immediately:

1. Read the book Mobile Integrated Healthcare: Approach to Implementation from Jones and Bartlett Learning. It provides an excellent overview of the steps toward EMS 3.0 you can take in your local community.

2. Visit the NAEMT MIH-CP Knowledge Center. It contains excellent resources that are updated regularly to help you learn about the transformation movement.

3. Attend the upcoming EMS Transformation Summit in Washington, D.C. This annual educational conference is specifically focused on the attributes of the 3.0 transformation.

4. Start talking to your local health care stakeholders. Find out what their concerns are and educate them on the ways your EMS agency can help them meet their Triple Aim goals.

5. Enroll in the IHI Open School program. This educational offering teaches you how to do quality improvement in health care. Yes, EMS is health care and the IHI Open School will arm you with the knowledge and skills to do transformation. NAEMT has full-tuition scholarships available as a member benefit for NAEMT members.

6. Enroll in the Academy of International Mobile Healthcare Integration (AIMHI) email news distribution list. AIMHI regularly sends out timely articles on the health care and EMS transformation. It is a great way to stay up to date on the changes that will affect you and your agency. To subscribe, send an email to MZavadsky@medstar911.org.



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Race to EMS 3.0 expands opportunities for EMS

Upon hearing the term "3.0", many people think of software release versions with the general understanding that "3.0" is newer and better than "2.0," and that likely there will be a "4.0" even newer and better version at some point in the future.

The current version of America's health care system has been described by many policy think tanks and economists as entering "Healthcare 3.0" [1,2]. Concurrent with this third major shift in health care, it is logical, perhaps even essential, that EMS is transforming into its third major revision, EMS 3.0.

But what exactly is EMS 3.0? 

EMS has, and always will be, the community's ultimate health care safety net, when all else fails, pressing three digits on a phone brings medical help to the caller. EMS will also always have a role transporting medically fragile patients from one facility to another. 

However, the advent of Healthcare 3.0 is creating new opportunities for EMS, roles that meet three main goals:

  1. Improve the patient's experience of care.
  2. Improve the health of the population.
  3. Reduce health care costs. 

These goals are often referred to as the Triple Aim developed by the Institute for Healthcare Improvement. Services provided as part of EMS 3.0 are designed to effectively navigate patients needing urgent or unscheduled care through the health care system to ensure they receive the right care, in the right place, at the right time. EMS 3.0 agencies fill gaps in patient care, preventing new or recurrent medical episodes to reduce ambulance transports, emergency department visits, hospital admissions and readmissions.

The effectiveness of the programs is rooted in collaboration. EMS 3.0 agencies help break down siloes in health care delivery models by coordinating and collaborating with a variety of community health care providers and agencies to deliver a broad spectrum of patient-centered preventive, primary, specialty and rehabilitative care outside of medical facilities. 

5 expanded roles for EMS

The expanded roles most commonly being undertaken by EMS systems operating in the 3.0 environment include the following:

1. Nurse triage
This typically involves the use of specially trained nurses as part of the 9-1-1 call taking process for low to no acuity 9-1-1 calls. Nurses use their training, along with decision support tools to help callers find more appropriate outcomes for their call as opposed to an ambulance to an emergency department. 

For example, a mom calling 9-1-1 for a child with an ear ache and fever could get an appointment with a pediatric clinic, or even self-care at-home instructions with a follow-up pediatrician appointment the next morning. EMS systems such as MedStar, Mesa Fire and Medical, REMSA, Salt Lake City Fire and King County, Washington are using 9-1-1 Nurse Triage. 

Some agencies are using nurses in their communications center to both receive calls and make outbound calls to follow-up on high risk patients. The nurses and help assure patients are safe at home, have and keep medical appointments or answer any questions patients may have. Northwell Health Center for EMS in Syosset, New York is doing that type of program.

2. Post discharge follow-up care
EMS personnel are being used in a growing number of communities to follow-up with patients and assure a safe transition from the hospital to the home. Crews complete one or two post discharge visits for things like in-home safety and fall risk assessments, medication inventories and a review of all discharge instructions while the patient is at home and in a way that the patient may be better able to comprehend the instructions. 

EMS agencies such as Procare Integrated Health and Transport in Baltimore, MedEx Ambulance in Chicago and Albuquerque Ambulance are operating these types of programs. Taking that concept a step further, a growing number of agencies are enrolling patients in 30-day post discharge readmission prevention programs, conducting a series of follow-up visits and even 9-1-1 intervention and redirection if the patient calls 9-1-1. MedStar Mobile Healthcare, REMSA, Mesa Fire and Medical and several other agencies are doing these types of interventions.

3. Chronic disease management and support
Some patients need assistance managing chronic diseases or behavioral health issues. Because EMS is available 24/7/365, numerous EMS systems have formal partnerships with hospitals, home health agencies, hospice agencies and payers to help these patients during a longer enrollment.

Specially trained paramedics make routine home visits and are available for any episodic needs these patients may have. The goals of these programs are to help the patient use their patient centered medical homes more effectively and prevent unnecessary 9-1-1, emergency department and inpatient hospital use. REMSA, Northwell, Mesa Fire and Medical, McKinney (TX) Fire Department and San Diego Fire are examples of operating programs for this intervention.

4. Ambulance transport alternatives
A few EMS systems are operating under protocols that train paramedics to do enhanced assessments in the field on 9-1-1 patients and allows these paramedics to offer low-acuity patients the option of being transported to destinations other than emergency departments. These programs are in operation at REMSA and three sites in California as part of the California Community Paramedic Pilot Projects (Carlsbad Fire, San Diego Fire, and Glendale Fire).

5. Payment alternatives
Since 1965, EMS has been paid based on a transport model, we are suppliers of transportation, and as such, are typically only paid to transport patients requiring medically necessary ambulance transport. Some 3.0 payers are realizing that if they keep paying EMS only to transport, then generally, that is what we are going to do. 

Payers in Fort Worth, Missouri and Reno are getting ready to test economic models for EMS that decouple the payment from transport. These models could be a payment for the response, regardless of transport or not, payment for transport to alternative destinations or even population-based capitated per member per month rates that incentivize the EMS agency to not even have to respond to calls.

As you can see, the EMS 3.0 transformation is already out of the gate with many agencies capitalizing on the changing health care dynamics test alternate service delivery and economic models. 

References
1. Healthcare 3.0: Healthcare for the new normal

2. Healthcare 3.0: Unlocking the value of big data  



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5 simulation scenarios to teach capnography to BLS providers

EMTs can easily learn how to use capnography as a patient assessment and monitoring tool

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An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations

Abstract

We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.



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Comparative Analysis of Mutational Profile of Sonic hedgehog Gene in Gallbladder Cancer

Abstract

Background

Gallbladder cancer has high incidence in northeastern India; mortality too is high as the disease is often diagnosed late. Numerous studies have shown the role of sonic hedgehog (shh) in different cancers, an important ligand of the hedgehog signaling pathway.

Aim

This study was carried out to evaluate the shh gene mutations in gallbladder cancer patients.

Methods

PCR-SSCP was performed for shh gene in 50 samples each of gallbladder cancer, cholelithiasis, and control. The samples showing aberration in banding pattern were sequenced.

Results

Variation in banding pattern was observed in 20% gallbladder cancer cases, 10% in cholelithiasis, and none of the control (χ 2 = 11.111; p < 0.05). Sequencing results revealed seven novel point mutations in GBC cases. These novel mutations were found to be associated with histopathology (p < 0.05) and stage (p < 0.05) of gallbladder cancer.

Conclusion

This study reveals several novel individual and repetitive mutations of shh gene in GBC and cholelithiasis samples that may be used as diagnostic markers for gallbladder carcinogenesis.



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When It Rains It Pours: Evolving, Complicated Small Intestinal Crohn’s Disease



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Mutation Detection of Fibroblast Growth Factor Receptor 3 for Infiltrative Hepatocellular Carcinoma by Whole-Exome Sequencing

Abstract

Background

Gene data on infiltrative hepatocellular carcinoma (iHCC) are still unknown.

Aims

This study aims to identify the gene expression signature of iHCC compared with single nodular (SN)-type HCC according to the gross classification.

Methods

The whole-exome sequencing was performed in six matched HCC tumor/normal pairs (three infiltrative type and three single nodular type) from six patients who received curative hepatectomy. Subsequent validation using Sanger sequencing and real-time PCR was performed in 30 HCC tumor samples (15 infiltrative type and 15 single nodular type).

Results

Following whole-exome sequencing, Sanger sequencing, and bioinformatics analysis, it revealed significant difference of iHCC from SN-type HCC in gene patterns. Particularly, a typical growth factor receptor tyrosine kinase FGFR3 was predominantly mutated in iHCC. One nonsynonymous variant c.G285T (p.Q95H) and five additional mutations (c.G938A:p.G313D, c.G1291A:p.A431T, c.C1355G:p.T452R, c.C1377T:p.L459L, and c.A1445T:p.E482V) were investigated by whole-exome and Sanger sequencing, respectively. Immunohistochemical studies confirmed the specific expression of FGFR3 in iHCC samples.

Conclusion

Our studies indicated that FGFR3 may be a candidate oncogene in tumor progression and a promising therapeutic target in iHCC patients who had early recurrence.



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One-port video-assisted thoracic surgery versus three-port video-assisted thoracic surgery for primary spontaneous pneumothorax: a meta-analysis

Abstract

Objective

To further understand the effects of video-assisted thoracic surgery (VATS) with one-port versus three-port VATS for primary spontaneous pneumothorax (PSP).

Methods

In this study, we searched information from the PubMed, Cochrane Library, Embase, ScienceDirect, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Data databases from inception to September 2015 to collect data of randomized controlled trials (RCTs) and cohort studies about one-port VATS versus three-port VATS for PSP. Two independent authors were committed to screen literature, extract data, and assess the risk of bias of related studies. Then, we used the RevMan 5.20 software for a meta-analysis of one-port VATS versus three-port VATS for PSP.

Results

Six cohort studies involving 310 patients were finally selected in this meta-analysis. The results of our study indicate that one-port VATS had a shorter hospital stay (SMD = −0.39, 95 % CI −0.69 to 0.09, P = 0.01), lower VAS score of 24-h post-operative pain (SMD = −0.78, 95 % CI −1.40 to −0.52, P < 0.00001), shorter chest drainage time (SMD = −0.68, 95 % CI −1.15 to −0.22, P = 0.004), and lower incidence of post-operative paraesthesia (OR = 0.13, 95 % CI 0.06 to 0.29, P < 0.00001) compared with three-port VATS. However, one-port VATS had a lower patient satisfaction score at 24 h (SMD = −0.65, 95 % CI −0.95 to −0.35, P < 0.0001) and 48 h (SMD = −0.46, 95 % CI −0.71 to −0.21, P = 0.0002). No differences in the recurrence of pneumothorax (OR = 0.58, 95 % CI 0.20 to 1.67, P = 0.32), the operation time (SMD = 1.01, 95 % CI −4.63 to 2.60, P = 0.58), and the satisfaction score at 72 h (SMD = −0.11, 95 % CI −0.44 to 0.22, P < 0.00001) were noted between the groups.

Conclusion

Current evidence suggests that one-port VATS may have certain advantages over three-port VATS for PSP. More large-scale and high-quality studies are needed for authentication.



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Techniques and short-term outcomes for total minimally invasive Ivor Lewis esophageal resection in distal esophageal and gastroesophageal junction cancers: pooled data from six European centers

Abstract

Introduction

Esophagectomy for cancer can be performed in a two-stage procedure with an intrathoracic anastomosis: the Ivor Lewis esophagectomy. A growing incidence of distal and gastroesophageal junction adenocarcinomas and increasing use of minimally invasive techniques have prompted interest in this procedure. The aim of this study was to assess short-term results of minimally invasive Ivor Lewis esophagectomy (MIE-IL).

Methods

A retrospective cohort study was performed from June 2007 until September 2014, including patients that underwent MIE-IL for distal esophageal and gastroesophageal junction cancer in six different hospitals in the Netherlands and Spain. Data were collected with regard to operative techniques, pathology and postoperative complications.

Results

In total, 282 patients underwent MIE-IL, of which 90.2 % received neoadjuvant therapy. Anastomotic leakage was observed in 43 patients (15.2 %), of whom 13 patients (4.6 %) had empyema, necessitating thoracotomy for decortication. With an aggressive treatment of complications, the 30-day and in-hospital mortality rate was 2.1 %. An R0-resection was obtained in 92.5 % of the patients. After neoadjuvant therapy, 20.1 % of patients had a complete response.

Conclusions

Minimally invasive Ivor Lewis esophagectomy for distal esophageal and gastroesophageal junction adenocarcinomas is an upcoming approach for reducing morbidity caused by laparotomy and thoracotomy. Anastomotic leakage rate is still high possibly due to technical diversity of anastomotic techniques, and a high percentage of patients treated by neoadjuvant chemoradiotherapy. An aggressive approach to complications leads to a low mortality of 2.1 %. Further improvement and standardization in the anastomotic technique are needed in order to perform a safe intrathoracic anastomosis.



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Robotic surgery: current perceptions and the clinical evidence

Abstract

Background

It appears that a discrepancy exists between the perception of robotic-assisted surgery (RAS) and the current clinical evidence regarding robotic-assisted surgery among patients, healthcare providers, and hospital administrators. The purpose of this study was to assess whether or not such a discrepancy exists.

Methods

We administered survey questionnaires via face-to-face interviews with surgical patients (n = 101), healthcare providers (n = 58), and senior members of hospital administration (n = 6) at a community hospital that performs robotic surgery. The respondents were asked about their perception regarding the infection rate, operative time, operative blood loss, incision size, cost, length of hospital stay (LOS), risk of complications, precision and accuracy, tactile sensation, and technique of robotic-assisted surgery as compared with conventional laparoscopic surgery. We then performed a comprehensive literature review to assess whether or not these perceptions could be corroborated with clinical evidence.

Results

The majority of survey respondents perceived RAS as modality to decrease infection rate, increase operative time, decrease operative blood loss, smaller incision size, a shorter LOS, and a lower risk of complications, while increasing the cost. Respondents also believed that robotic surgery provides greater precision, accuracy, and tactile sensation, while improving intra-operative access to organs. A comprehensive literature review found little-to-no clinical evidence that supported the respondent's favorable perceptions of robotic surgery except for the increased costs, and precision and accuracy of the robotic-assisted technique.

Conclusions

There is a discrepancy between the perceptions of robotic surgery and the clinical evidence among patients, healthcare providers, and hospital administrators surveyed.



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Comparison of clinical outcome of laparoscopic versus open appendectomy for complicated appendicitis

Abstract

Background

Laparoscopic appendectomy is now the treatment of choice in uncomplicated appendicitis. To date its importance in the treatment of complicated appendicitis is not clearly defined.

Methods

From January 2005 to June 2013 a total of 1762 patients underwent appendectomy for the suspected diagnosis of appendicitis at our institution. Of these patients 1516 suffered from complicated appendicitis and were enrolled. In total 926 (61 %) underwent open appendectomy (OA) and 590 (39 %) underwent laparoscopic appendectomy (LA). The following parameters were retrospectively analyzed: age, sex, operative times, histology, length of hospital stay, 30-day morbidity focusing on occurrence of surgical site infections, intraabdominal abscess formation, postoperative ileus and appendiceal stump insufficiency, conversion rate, use of endoloops and endostapler.

Results

A statistically significant difference in operative time was observed between the laparoscopic and the open group (64.5 vs. 60 min; p = 0.002). Median length of hospitalization was significantly shorter in the laparoscopic group (p < 0.000). Surgical site infections occurred exclusively after OA (38 vs. 0 patients). Intraabdominal abscess formation occurred statistically significantly more often after LA (2 vs. 10 patients; p = 0.002). There were no statistical significances concerning the occurrence of postoperative ileus (p = 0.261) or appendiceal stump insufficiencies (p = 0.076).

Conclusions

The laparoscopic approach for complicated appendicitis is a safe and feasible procedure. Surgeons should be aware of a potentially higher incidence of intraabdominal abscess formation following LA. Use of endobags , inversion of the appendiceal stump and carefully conducted local irrigation of the abdomen in a supine position may reduce the incidence of abscess formation.



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Domestically produced Chinese minimally invasive surgical robot system “Micro Hand S” is applied to clinical surgery preliminarily in China

Abstract

Objective

To develop and validate one low-cost and easy-use domestically produced Chinese minimally invasive surgical robot system "Micro Hand S" that surgeons can use to resolve the complicated surgeries challenge.

Methods

From April 2014 to April 2015, one patient with gastric perforation, three patients with acute appendicitis, five patients with acute cholecystitis, and one patient with right colon cancer underwent robotic-assisted surgeries. Eight of these patients were followed for 1 month, and pre- and postoperative changes in blood route test and hepatorenal function examination, surgery duration, hospital stay, total robotic setup time, total robotic operation time, intraoperative blood loss, total postoperative drainage amount, duration of bearing drainage tubes were recorded. Two patients withdrew from the study because of individual privacies.

Results

We accomplished surgical procedures using "Micro Hand S." No intraoperative complications or technical problems were encountered. All patients recovered and discharged from hospital without complications.

Conclusions

The domestic surgical robot system "Micro Hand S" was validated as safe and effective through these clinical cases. The proposed design method is an effective way to make "Micro Hand S" become low-cost and easy-use robot system.



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Creatine Loading Does Not Preserve Muscle Mass or Strength During Leg Immobilization in Healthy, Young Males: A Randomized Controlled Trial

Abstract

Background

A short period of leg immobilization leads to rapid loss of muscle mass and strength. Creatine supplementation has been shown to increase lean body mass in active individuals and can be used to augment gains in muscle mass and strength during prolonged resistance-type exercise training.

Objective

Our objective was to investigate whether creatine loading can attenuate the loss of muscle mass and strength during short-term leg immobilization.

Methods

Healthy young men (n = 30; aged 23 ± 1 years; body mass index [BMI] 23.3 ± 0.5 kg/m−2) were randomly assigned to either a creatine or a placebo group. Subjects received placebo or creatine supplements (20 g/d) for 5 days before one leg was immobilized by means of a full-leg cast for 7 days. Muscle biopsies were taken before creatine loading, prior to and immediately after leg immobilization, and after 7 days of subsequent recovery. Quadriceps cross-sectional area (CSA) (computed tomography [CT] scan) and leg muscle strength (one-repetition maximum [1-RM] knee extension) were assessed before and immediately after immobilization and after 1 week of recovery. Data were analyzed using repeated measures analysis of variance (ANOVA). Data are presented consistently as mean ± standard error of the mean (SEM).

Results

There was a significant overall increase in muscle total creatine content following the 5-day loading phase (p = 0.049), which appeared driven by an increase in the creatine group (from 90 ± 9 to 107 ± 4 mmol/kg−1 dry muscle) with no apparent change in the placebo group (from 88 ± 4 to 90 ± 3 mmol/kg−1; p = 0.066 for time × treatment interaction). Quadriceps muscle CSA had declined by 465 ± 59 and 425 ± 69 mm2 (p < 0.01) in the creatine and placebo group, respectively, with no differences between groups (p = 0.76). Leg muscle strength decreased from 56 ± 4 to 53 ± 4 kg in the creatine and from 59 ± 3 to 53 ± 3 kg in the placebo group, with no differences between groups (p = 0.20). Muscle fiber size did not change significantly over time in either group (p > 0.05). When non-responders to creatine loading were excluded (n = 6), responders (n = 8; total creatine content increasing from 70 to 106 mmol/kg−1) showed similar findings, with no signs of preservation of muscle mass or strength during immobilization. During the subsequent recovery phase, no differences in muscle mass or strength were found between the two groups (p > 0.05).

Conclusion

Creatine supplementation prior to and during leg immobilization does not prevent or attenuate the loss of muscle mass or strength during short-term muscle disuse.

NIH Clinical Trial Registration Number: NCT01894737 (http://ift.tt/PmpYKN).



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Iowa dispatcher retires after 40-year career

By EMS1 Staff

MASON CITY, Iowa — After 40 years of service, dispatcher Diane Sanchez bid farewell to her colleagues last week. 

Sanchez, 58,  began her career as a dispatcher for the police department, and stayed on after city and county dispatch centers combined in 2008, Globe Gazette reported. 

The veteran dispatcher said she will miss the "interesting calls you get and the opportunity to help people."

While reflecting on her career, Sanchez said the technology for dispatchers and call centers has greatly changed since she first started.

When asked about her plans during retirement, Sanchez said she's going to take it easy.



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Identification of Genes Mediating Drosophila Follicle Cell Progenitor Differentiation by Screening for Modifiers of GAL4::UAS Variegation

The Drosophila melanogaster ovarian follicle cell lineage provides a powerful system for investigating how epigenetic changes contribute to differentiation. Downstream from an epithelial stem cell, follicle progenitors undergo nine mitotic cell cycles before transitioning to the endocycle and initiating differentiation. During their proliferative phase, follicle progenitors experience Lsd1-dependent changes in epigenetic stability that can be monitored using GAL4::UAS variegation. Eventually, follicle progenitors acquire competence to respond to Delta, a Notch ligand present in the environment, which signals them to cease division and initiate differentiation. The time required to acquire competence determines the duration of mitotic cycling and hence the final number of follicle cells. We carried out a screen for dominant modifiers of variegation spanning nearly 70% of Drosophila euchromatin to identify new genes influencing follicle progenitor epigenetic maturation. The eight genes found include chromatin modifiers, but also cell cycle regulators and transcription factors. Five of the modifier genes accelerate the acquisition of progenitor competence and reduce follicle cell number, however, the other three genes affect follicle cell number in an unexpected manner.



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Genotyping-by-Sequencing-Based Investigation of the Genetic Architecture Responsible for a ~Sevenfold Increase in Soybean Seed Stearic Acid

Soybean oil is highly unsaturated but oxidatively unstable, rendering it nonideal for food applications. Until recently, the majority of soybean oil underwent partial chemical hydrogenation, which produces trans fats as an unavoidable consequence. Dietary intake of trans fats and most saturated fats are conclusively linked to negative impacts on cholesterol levels and cardiovascular health. Two major soybean oil breeding targets are: (1) to reduce or eliminate the need for chemical hydrogenation, and (2) to replace the functional properties of partially hydrogenated soybean oil. One potential solution is the elevation of seed stearic acid, a saturated fat which has no negative impacts on cardiovascular health, from 3 to 4% in typical cultivars to > 20% of the seed oil. We performed QTL analysis of a population developed by crossing two mutant lines, one with a missense mutation affecting a stearoyl-acyl-carrier protein desaturase gene resulting in ~11% seed stearic acid crossed to another mutant, A6, which has 24–28% seed stearic acid. Genotyping-by-sequencing (GBS)-based QTL mapping identified 21 minor and major effect QTL for six seed oil related traits and plant height. The inheritance of a large genomic deletion affecting chromosome 14 is the basis for largest effect QTL, resulting in ~18% seed stearic acid. This deletion contains SACPD-C and another gene(s); loss of both genes boosts seed stearic acid levels to ≥ 18%. Unfortunately, this genomic deletion has been shown in previous studies to be inextricably correlated with reduced seed yield. Our results will help inform and guide ongoing breeding efforts to improve soybean oil oxidative stability.



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Corrigendum



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One-Cell Doubling Evaluation by Living Arrays of Yeast, ODELAY!

Cell growth is a complex phenotype widely used in systems biology to gauge the impact of genetic and environmental perturbations. Due to the magnitude of genome-wide studies, resolution is often sacrificed in favor of throughput, creating a demand for scalable, time-resolved, quantitative methods of growth assessment. We present ODELAY (One-cell Doubling Evaluation by Living Arrays of Yeast), an automated and scalable growth analysis platform. High measurement density and single-cell resolution provide a powerful tool for large-scale multiparameter growth analysis based on the modeling of microcolony expansion on solid media. Pioneered in yeast but applicable to other colony forming organisms, ODELAY extracts the three key growth parameters (lag time, doubling time, and carrying capacity) that define microcolony expansion from single cells, simultaneously permitting the assessment of population heterogeneity. The utility of ODELAY is illustrated using yeast mutants, revealing a spectrum of phenotypes arising from single and combinatorial growth parameter perturbations.



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First in Vivo Batrachochytrium dendrobatidis Transcriptomes Reveal Mechanisms of Host Exploitation, Host-Specific Gene Expression, and Expressed Genotype Shifts

For generalist pathogens, host species represent distinct selective environments, providing unique challenges for resource acquisition and defense from host immunity, potentially resulting in host-dependent differences in pathogen fitness. Gene expression modulation should be advantageous, responding optimally to a given host and mitigating the costs of generalism. Batrachochytrium dendrobatidis (Bd), a fungal pathogen of amphibians, shows variability in pathogenicity among isolates, and within-strain virulence changes rapidly during serial passages through artificial culture. For the first time, we characterize the transcriptomic profile of Bd in vivo, using laser-capture microdissection. Comparison of Bd transcriptomes (strain JEL423) in culture and in two hosts (Atelopus zeteki and Hylomantis lemur), reveals >2000 differentially expressed genes that likely include key Bd defense and host exploitation mechanisms. Variation in Bd transcriptomes from different amphibian hosts demonstrates shifts in pathogen resource allocation. Furthermore, expressed genotype variant frequencies of Bd populations differ between culture and amphibian skin, and among host species, revealing potential mechanisms underlying rapid changes in virulence and the possibility that amphibian community composition shapes Bd evolutionary trajectories. Our results provide new insights into how changes in gene expression and infecting population genotypes can be key to the success of a generalist fungal pathogen.



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Correlations of Genotype with Climate Parameters Suggest Caenorhabditis elegans Niche Adaptations

Species inhabit a variety of environmental niches, and the adaptation to a particular niche is often controlled by genetic factors, including gene-by-environment interactions. The genes that vary in order to regulate the ability to colonize a niche are often difficult to identify, especially in the context of complex ecological systems and in experimentally uncontrolled natural environments. Quantitative genetic approaches provide an opportunity to investigate correlations between genetic factors and environmental parameters that might define a niche. Previously, we have shown how a collection of 208 whole-genome sequenced wild Caenorhabditis elegans can facilitate association mapping approaches. To correlate climate parameters with the variation found in this collection of wild strains, we used geographic data to exhaustively curate daily weather measurements in short-term (3 month), middle-term (one year), and long-term (three year) durations surrounding the date of strain isolation. These climate parameters were used as quantitative traits in association mapping approaches, where we identified 11 quantitative trait loci (QTL) for three climatic variables: elevation, relative humidity, and average temperature. We then narrowed the genomic interval of interest to identify gene candidates with variants potentially underlying phenotypic differences. Additionally, we performed two-strain competition assays at high and low temperatures to validate a QTL that could underlie adaptation to temperature and found suggestive evidence supporting that hypothesis.



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Multiplex shRNA Screening of Germ Cell Development by in Vivo Transfection of Mouse Testis

Spermatozoa are one of the few mammalian cell types that cannot be fully derived in vitro, severely limiting the application of modern genomic techniques to study germ cell biology. The current gold standard approach of characterizing single-gene knockout mice is slow as generation of each mutant line can take 6–9 months. Here, we describe an in vivo approach to rapid functional screening of germline genes based on a new nonsurgical, nonviral in vivo transfection method to deliver nucleic acids into testicular germ cells. By coupling multiplex transfection of short hairpin RNA (shRNA) constructs with pooled amplicon sequencing as a readout, we were able to screen many genes for spermatogenesis function in a quick and inexpensive experiment. We transfected nine mouse testes with a pilot pool of RNA interference (RNAi) against well-characterized genes to show that this system is highly reproducible and accurate. With a false negative rate of 18% and a false positive rate of 12%, this method has similar performance as other RNAi screens in the well-described Drosophila model system. In a separate experiment, we screened 26 uncharacterized genes computationally predicted to be essential for spermatogenesis and found numerous candidates for follow-up studies. Finally, as a control experiment, we performed a long-term selection screen in neuronal N2a cells, sampling shRNA frequencies at five sequential time points. By characterizing the effect of both libraries on N2a cells, we show that our screening results from testis are tissue-specific. Our calculations indicate that the current implementation of this approach could be used to screen thousands of protein-coding genes simultaneously in a single mouse testis. The experimental protocols and analysis scripts provided will enable other groups to use this procedure to study diverse aspects of germ cell biology ranging from epigenetics to cell physiology. This approach also has great promise as an applied tool for validating diagnoses made from medical genome sequencing, or designing synthetic biological sequences that can act as potent and highly specific male contraceptives.



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CRISPR/Cas9-Induced Double-Strand Break Repair in Arabidopsis Nonhomologous End-Joining Mutants

Double-strand breaks (DSBs) are one of the most harmful DNA lesions. Cells utilize two main pathways for DSB repair: homologous recombination (HR) and nonhomologous end-joining (NHEJ). NHEJ can be subdivided into the KU-dependent classical NHEJ (c-NHEJ) and the more error-prone KU-independent backup-NHEJ (b-NHEJ) pathways, involving the poly (ADP-ribose) polymerases (PARPs). However, in the absence of these factors, cells still seem able to adequately maintain genome integrity, suggesting the presence of other b-NHEJ repair factors or pathways independent from KU and PARPs. The outcome of DSB repair by NHEJ pathways can be investigated by using artificial sequence-specific nucleases such as CRISPR/Cas9 to induce DSBs at a target of interest. Here, we used CRISPR/Cas9 for DSB induction at the Arabidopsis cruciferin 3 (CRU3) and protoporphyrinogen oxidase (PPO) genes. DSB repair outcomes via NHEJ were analyzed using footprint analysis in wild-type plants and plants deficient in key factors of c-NHEJ (ku80), b-NHEJ (parp1 parp2), or both (ku80 parp1 parp2). We found that larger deletions of >20 bp predominated after DSB repair in ku80 and ku80 parp1 parp2 mutants, corroborating with a role of KU in preventing DSB end resection. Deletion lengths did not significantly differ between ku80 and ku80 parp1 parp2 mutants, suggesting that a KU- and PARP-independent b-NHEJ mechanism becomes active in these mutants. Furthermore, microhomologies and templated insertions were observed at the repair junctions in the wild type and all mutants. Since these characteristics are hallmarks of polymerase -mediated DSB repair, we suggest a possible role for this recently discovered polymerase in DSB repair in plants.



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Efficient Screening of CRISPR/Cas9-Induced Events in Drosophila Using a Co-CRISPR Strategy

Genome editing using the Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) and associated nuclease (Cas9) enables specific genetic modifications, including deletions, insertions, and substitutions in numerous organisms, such as the fruit fly Drosophila melanogaster. One challenge of the CRISPR/Cas9 system can be the laborious and time-consuming screening required to find CRISPR-induced modifications due to a lack of an obvious phenotype and low frequency after editing. Here we apply the successful co-CRISPR technique in Drosophila to simultaneously target a gene of interest and a marker gene, ebony, which is a recessive gene that produces dark body color and has the further advantage of not being a commonly used transgenic marker. We found that Drosophila broods containing higher numbers of CRISPR-induced ebony mutations ("jackpot" lines) are significantly enriched for indel events in a separate gene of interest, while broods with few or no ebony offspring showed few mutations in the gene of interest. Using two different PAM sites in our gene of interest, we report that ~61% (52–70%) of flies from the ebony-enriched broods had an indel in DNA near either PAM site. Furthermore, this marker mutation system may be useful in detecting the less frequent homology-directed repair events, all of which occurred in the ebony-enriched broods. By focusing on the broods with a significant number of ebony flies, successful identification of CRISPR-induced events is much faster and more efficient. The co-CRISPR technique we present significantly improves the screening efficiency in identification of genome-editing events in Drosophila.



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Regulatory Architecture of Gene Expression Variation in the Threespine Stickleback Gasterosteus aculeatus

Much adaptive evolutionary change is underlain by mutational variation in regions of the genome that regulate gene expression rather than in the coding regions of the genes themselves. An understanding of the role of gene expression variation in facilitating local adaptation will be aided by an understanding of underlying regulatory networks. Here, we characterize the genetic architecture of gene expression variation in the threespine stickleback (Gasterosteus aculeatus), an important model in the study of adaptive evolution. We collected transcriptomic and genomic data from 60 half-sib families using an expression microarray and genotyping-by-sequencing, and located expression quantitative trait loci (eQTL) underlying the variation in gene expression in liver tissue using an interval mapping approach. We identified eQTL for several thousand expression traits. Expression was influenced by polymorphism in both cis- and trans-regulatory regions. Trans-eQTL clustered into hotspots. We did not identify master transcriptional regulators in hotspot locations: rather, the presence of hotspots may be driven by complex interactions between multiple transcription factors. One observed hotspot colocated with a QTL recently found to underlie salinity tolerance in the threespine stickleback. However, most other observed hotspots did not colocate with regions of the genome known to be involved in adaptive divergence between marine and freshwater habitats.



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Candida albicans Is Resistant to Polyglutamine Aggregation and Toxicity

Disruption of protein quality control can be detrimental, having toxic effects on single cell organisms and contributing to neurodegenerative diseases such as Alzheimer's, Parkinson's and Huntington's in humans. Here, we examined the effects of polyglutamine (polyQ) aggregation in a major fungal pathogen of humans, Candida albicans, with the goal of identifying new approaches to disable this fungus. However, we discovered that expression of polyQ stretches up to 230Q had no effect on C. albicans ability to grow and withstand proteotoxic stress. Bioinformatics analysis demonstrates that C. albicans has a similarly glutamine-rich proteome to the unicellular fungus Saccharomyces cerevisiae, which exhibits polyQ toxicity with as few as 72Q. Surprisingly, global transcriptional profiles indicated no significant change upon induction of up to 230Q. Proteomic analysis highlighted two key interactors of 230Q, Sis1 and Sgt2; however, loss of either protein had no additional effect on C. albicans toxicity. Our data suggest that C. albicans has evolved powerful mechanisms to overcome the toxicity associated with aggregation-prone proteins, providing a unique model for studying polyQ-associated diseases.



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Time-Course Analysis of Gene Expression During the Saccharomyces cerevisiae Hypoxic Response

Many cells experience hypoxia, or low oxygen, and respond by dramatically altering gene expression. In the yeast Saccharomyces cerevisiae, genes that respond are required for many oxygen-dependent cellular processes, such as respiration, biosynthesis, and redox regulation. To more fully characterize the global response to hypoxia, we exposed yeast to hypoxic conditions, extracted RNA at different times, and performed RNA sequencing (RNA-seq) analysis. Time-course statistical analysis revealed hundreds of genes that changed expression by up to 550-fold. The genes responded with varying kinetics suggesting that multiple regulatory pathways are involved. We identified most known oxygen-regulated genes and also uncovered new regulated genes. Reverse transcription-quantitative PCR (RT-qPCR) analysis confirmed that the lysine methyltransferase EFM6 and the recombinase DMC1, both conserved in humans, are indeed oxygen-responsive. Looking more broadly, oxygen-regulated genes participate in expected processes like respiration and lipid metabolism, but also in unexpected processes like amino acid and vitamin metabolism. Using principle component analysis, we discovered that the hypoxic response largely occurs during the first 2 hr and then a new steady-state expression state is achieved. Moreover, we show that the oxygen-dependent genes are not part of the previously described environmental stress response (ESR) consisting of genes that respond to diverse types of stress. While hypoxia appears to cause a transient stress, the hypoxic response is mostly characterized by a transition to a new state of gene expression. In summary, our results reveal that hypoxia causes widespread and complex changes in gene expression to prepare the cell to function with little or no oxygen.



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A New Chicken Genome Assembly Provides Insight into Avian Genome Structure

The importance of the Gallus gallus (chicken) as a model organism and agricultural animal merits a continuation of sequence assembly improvement efforts. We present a new version of the chicken genome assembly (Gallus_gallus-5.0; GCA_000002315.3), built from combined long single molecule sequencing technology, finished BACs, and improved physical maps. In overall assembled bases, we see a gain of 183 Mb, including 16.4 Mb in placed chromosomes with a corresponding gain in the percentage of intact repeat elements characterized. Of the 1.21 Gb genome, we include three previously missing autosomes, GGA30, 31, and 33, and improve sequence contig length 10-fold over the previous Gallus_gallus-4.0. Despite the significant base representation improvements made, 138 Mb of sequence is not yet located to chromosomes. When annotated for gene content, Gallus_gallus-5.0 shows an increase of 4679 annotated genes (2768 noncoding and 1911 protein-coding) over those in Gallus_gallus-4.0. We also revisited the question of what genes are missing in the avian lineage, as assessed by the highest quality avian genome assembly to date, and found that a large fraction of the original set of missing genes are still absent in sequenced bird species. Finally, our new data support a detailed map of MHC-B, encompassing two segments: one with a highly stable gene copy number and another in which the gene copy number is highly variable. The chicken model has been a critical resource for many other fields of study, and this new reference assembly will substantially further these efforts.



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Cytogenetic and Molecular Characterization of B-Genome Introgression Lines of Brassica napus L.

Brassica napus introgression lines (ILs), having B-genome segments from B. carinata, were assessed genetically for extent of introgression and phenotypically for siliqua shatter resistance. Introgression lines had 7–9% higher DNA content, were meiotically stable, and had almost normal pollen fertility/seed set. Segment introgressions were confirmed by fluorescent genomic in situ hybridization (fl-GISH), SSR analyses, and SNP studies. Genotyping with 48 B-genome specific SSRs detected substitutions from B3, B4, B6, and B7 chromosomes on 39 of the 69 ILs whereas SNP genotyping detected a total of 23 B-segments (≥3 Mb) from B4, B6, and B7 introgressed into 10 of the 19 (C1, C2, C3, C5, C6, C8, C9, A3, A9, A10) chromosomes in 17 ILs. The size of substitutions varied from 3.0 Mb on chromosome A9 (IL59) to 42.44 Mb on chromosome C2 (IL54), ranging from 7 to 83% of the recipient chromosome. Average siliqua strength in ILs was observed to be higher than that of B. napus parents (2.2–6.0 vs. 1.9–4.0 mJ) while siliqua strength in some of the lines was almost equal to that of the donor parent B. carinata (6.0 vs.7.2 mJ). These ILs, with large chunks of substituted B-genome, can prove to be a useful prebreeding resource for germplasm enhancement in B. napus, especially for siliqua shatter resistance.



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Imputation-Based Fine-Mapping Suggests That Most QTL in an Outbred Chicken Advanced Intercross Body Weight Line Are Due to Multiple, Linked Loci

The Virginia chicken lines have been divergently selected for juvenile body weight for more than 50 generations. Today, the high- and low-weight lines show a >12-fold difference for the selected trait, 56-d body weight. These lines provide unique opportunities to study the genetic architecture of long-term, single-trait selection. Previously, several quantitative trait loci (QTL) contributing to weight differences between the lines were mapped in an F2-cross between them, and these were later replicated and fine-mapped in a nine-generation advanced intercross of them. Here, we explore the possibility to further increase the fine-mapping resolution of these QTL via a pedigree-based imputation strategy that aims to better capture the genetic diversity in the divergently selected, but outbred, founder lines. The founders of the intercross were high-density genotyped, and then pedigree-based imputation was used to assign genotypes throughout the pedigree. Imputation increased the marker density 20-fold in the selected QTL, providing 6911 markers for the subsequent analysis. Both single-marker association and multi-marker backward-elimination analyses were used to explore regions associated with 56-d body weight. The approach revealed several statistically and population structure independent associations and increased the mapping resolution. Further, most QTL were also found to contain multiple independent associations to markers that were not fixed in the founder populations, implying a complex underlying architecture due to the combined effects of multiple, linked loci perhaps located on independent haplotypes that still segregate in the selected lines.



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Cfs1p, a Novel Membrane Protein in the PQ-Loop Family, Is Involved in Phospholipid Flippase Functions in Yeast

Type 4 P-type ATPases (P4-ATPases) function as phospholipid flippases, which translocate phospholipids from the exoplasmic leaflet to the cytoplasmic leaflet of the lipid bilayer, to generate and maintain asymmetric distribution of phospholipids at the plasma membrane and endosomal/Golgi membranes. The budding yeast Saccharomyces cerevisiae has four heteromeric flippases (Drs2p, Dnf1p, Dnf2p, and Dnf3p), associated with the Cdc50p family noncatalytic subunit, and one monomeric flippase, Neo1p. They have been suggested to function in vesicle formation in membrane trafficking pathways, but details of their mechanisms remain to be clarified. Here, to search for novel factors that functionally interact with flippases, we screened transposon insertional mutants for strains that suppressed the cold-sensitive growth defect in the cdc50 mutant. We identified a mutation of YMR010W encoding a novel conserved membrane protein that belongs to the PQ-loop family including the cystine transporter cystinosin and the SWEET sugar transporters. We named this gene CFS1 (cdc fifty suppressor 1). GFP-tagged Cfs1p was partially colocalized with Drs2p and Neo1p to endosomal/late Golgi membranes. Interestingly, the cfs1 mutation suppressed growth defects in all flippase mutants. Accordingly, defects in membrane trafficking in the flippase mutants were also suppressed. These results suggest that Cfs1p and flippases function antagonistically in membrane trafficking pathways. A growth assay to assess sensitivity to duramycin, a phosphatidylethanolamine (PE)-binding peptide, suggested that the cfs1 mutation changed PE asymmetry in the plasma membrane. Cfs1p may thus be a novel regulator of phospholipid asymmetry.



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The Neurospora Transcription Factor ADV-1 Transduces Light Signals and Temporal Information to Control Rhythmic Expression of Genes Involved in Cell Fusion

Light and the circadian clock have a profound effect on the biology of organisms through the regulation of large sets of genes. Toward understanding how light and the circadian clock regulate gene expression, we used genome-wide approaches to identify the direct and indirect targets of the light-responsive and clock-controlled transcription factor ADV-1 in Neurospora crassa. A large proportion of ADV-1 targets were found to be light- and/or clock-controlled, and enriched for genes involved in development, metabolism, cell growth, and cell fusion. We show that ADV-1 is necessary for transducing light and/or temporal information to its immediate downstream targets, including controlling rhythms in genes critical to somatic cell fusion. However, while ADV-1 targets are altered in predictable ways in adv-1 cells in response to light, this is not always the case for rhythmic target gene expression. These data suggest that a complex regulatory network downstream of ADV-1 functions to generate distinct temporal dynamics of target gene expression relative to the central clock mechanism.



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Analysis of Ribosome-Associated mRNAs in Rice Reveals the Importance of Transcript Size and GC Content in Translation

Gene expression is controlled at transcriptional and post-transcriptional levels including decoding of messenger RNA (mRNA) into polypeptides via ribosome-mediated translation. Translational regulation has been intensively studied in the model dicot plant Arabidopsis thaliana, and in this study, we assessed the translational status [proportion of steady-state mRNA associated with ribosomes] of mRNAs by Translating Ribosome Affinity Purification followed by mRNA-sequencing (TRAP-seq) in rice (Oryza sativa), a model monocot plant and the most important food crop. A survey of three tissues found that most transcribed rice genes are translated whereas few transposable elements are associated with ribosomes. Genes with short and GC-rich coding regions are overrepresented in ribosome-associated mRNAs, suggesting that the GC-richness characteristic of coding sequences in grasses may be an adaptation that favors efficient translation. Transcripts with retained introns and extended 5' untranslated regions are underrepresented on ribosomes, and rice genes belonging to different evolutionary lineages exhibited differential enrichment on the ribosomes that was associated with GC content. Genes involved in photosynthesis and stress responses are preferentially associated with ribosomes, whereas genes in epigenetic regulation pathways are the least enriched on ribosomes. Such variation is more dramatic in rice than that in Arabidopsis and is correlated with the wide variation of GC content of transcripts in rice. Taken together, variation in the translation status of individual transcripts reflects important mechanisms of gene regulation, which may have a role in evolution and diversification.



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Assortative Mating and Linkage Disequilibrium

Assortative mating has been suggested to result in an increase in heritability and additive genetic variance through an increase in linkage disequilibrium. The impact of assortative mating on linkage disequilibrium was explicitly examined for the two-locus model of Wright (1921) and two selective assortative mating models. For the Wright (1921) model, when the proportion of assortative mating was high, positive linkage disequilibrium was generated. However, when the proportion of assortative mating was similar to that found in some studies, the amount of linkage disequilibrium was quite low. In addition, the amount of linkage disequilibrium was independent of the level of recombination. For two selective assortative models, the amount of linkage disequilibrium was a function of the amount of recombination. For these models, the linkage disequilibrium generated was negative mainly because repulsion heterozygotes were favored over coupling heterozygotes. From these findings, the impact of assortative mating on linkage disequilibrium, and consequently heritability and additive genetic variance, appears to be small and model-specific.



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Dissecting Gene Expression Changes Accompanying a Ploidy-Based Phenotypic Switch

Aneuploidy, a state in which the chromosome number deviates from a multiple of the haploid count, significantly impacts human health. The phenotypic consequences of aneuploidy are believed to arise from gene expression changes associated with the altered copy number of genes on the aneuploid chromosomes. To dissect the mechanisms underlying altered gene expression in aneuploids, we used RNA-seq to measure transcript abundance in colonies of the haploid Saccharomyces cerevisiae strain F45 and two aneuploid derivatives harboring disomies of chromosomes XV and XVI. F45 colonies display complex "fluffy" morphologies, while the disomic colonies are smooth, resembling laboratory strains. Our two disomes displayed similar transcriptional profiles, a phenomenon not driven by their shared smooth colony morphology nor simply by their karyotype. Surprisingly, the environmental stress response (ESR) was induced in F45, relative to the two disomes. We also identified genes whose expression reflected a nonlinear interaction between the copy number of a transcriptional regulatory gene on chromosome XVI, DIG1, and the copy number of other chromosome XVI genes. DIG1 and the remaining chromosome XVI genes also demonstrated distinct contributions to the effect of the chromosome XVI disome on ESR gene expression. Expression changes in aneuploids appear to reflect a mixture of effects shared between different aneuploidies and effects unique to perturbing the copy number of particular chromosomes, including nonlinear copy number interactions between genes. The balance between these two phenomena is likely to be genotype- and environment-specific.



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Vaccination Coverage and Timelines Among Children 0–6 Months in Kinshasa, the Democratic Republic of Congo: A Prospective Cohort Study

Abstract

Objectives The Democratic Republic of Congo (DR Congo) is one of the ten countries, which accounts for 60% of unvaccinated children worldwide. The aim of this study was to assess predictors of incomplete and untimely immunization among a cohort of infants recruited at birth and followed up through 24 weeks in Kinshasa. Methods Complete immunization for each vaccine was defined as receiving all the recommended doses. Untimely immunization was defined as receiving the given dose before (early) or after (delayed) the recommended time window. Infants not immunized by the end of the follow-up time were considered missing. Multivariate hierarchical model and generalized logistic model were used to assess the independent contribution of each socio-economic and demographic factors considered to complete immunization and timeliness, respectively. Results Overall, of 975 infants from six selected clinics included in the analysis 84.7% were fully immunized the three doses of DTP or four doses of Polio by 24 weeks of age. Independently of the vaccine considered, the strongest predictor of incomplete and untimely immunization was the clinic in which the infant was enrolled. This association was strengthened after adjustment for socio-economic and demographic characteristics. Education and the socio-economic status also were predictive of completion and timeliness of immunization in our cohort. Discussion In conclusion, the strongest predictor for incomplete and untimely immunization among infants in Kinshasa was the clinics in which they were enrolled. The association was likely due to the user fee for well-baby clinic visits and its varying structure by clinic.



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Validating proposed migration equation and parameters' values as a tool to reproduce and predict 137Cs vertical migration activity in Spanish soils

Publication date: April 2017
Source:Journal of Environmental Radioactivity, Volumes 169–170
Author(s): C. Olondo, F. Legarda, M. Herranz, R. Idoeta
This paper shows the procedure performed to validate the migration equation and the migration parameters' values presented in a previous paper (Legarda et al., 2011) regarding the migration of 137Cs in Spanish mainland soils.In this paper, this model validation has been carried out checking experimentally obtained activity concentration values against those predicted by the model. This experimental data come from the measured vertical activity profiles of 8 new sampling points which are located in northern Spain. Before testing predicted values of the model, the uncertainty of those values has been assessed with the appropriate uncertainty analysis. Once establishing the uncertainty of the model, both activity concentration values, experimental versus model predicted ones, have been compared. Model validation has been performed analyzing its accuracy, studying it as a whole and also at different depth intervals. As a result, this model has been validated as a tool to predict 137Cs behaviour in a Mediterranean environment.

Graphical abstract

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Increased morbidity and mortality in cardiac patients undergoing fundoplication

Pediatric Surgery International

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Efficacy and safety of ledipasvir/sofosbuvir with and without ribavirin in patients with chronic hepatitis C virus genotype 1 infection: A meta-analysis

International Journal of Infectious Diseases

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Liver fibrosis: Review of current imaging and MRI quantification techniques

Journal of Magnetic Resonance Imaging

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Decreasing black-white disparities in colorectal cancer incidence and stage at presentation in the United States

Cancer Epidemiology, Biomarkers & Prevention

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Variations in IL-1R1 gene influence risk for hepatitis B virus infection of children in a Han Chinese population

International Journal of Infectious Diseases

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Efficacy and safety of high dose dual therapy for Helicobacter pylori rescue therapy: A systematic review and meta-analysis

Journal of Digestive Diseases

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Association of grade of non-alcoholic fatty liver disease and glycated albumin to glycated hemoglobin ratio in patients with type 2 diabetes mellitus

Diabetes Research and Clinical Practice

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Lung disease severity in idiopathic pulmonary fibrosis is more strongly associated with impedance measures of bolus reflux than pH parameters of acid reflux alone

Neurogastroenterology & Motility

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Age of transfused blood impacts perioperative outcomes among patients who undergo major gastrointestinal surgery

Annals of Surgery

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Effectiveness of a preoperative exercise and nutritional support program for elderly sarcopenic patients with gastric cancer

Gastric Cancer

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A retrospective cohort study of the influence of lifestyle factors on survival of patients undergoing surgery for colorectal cancer

Colorectal Disease

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Asymptomatic carriers contribute to nosocomial Clostridium difficile infection: A cohort study of 4508 patients

Gastroenterology

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Short- and long-term outcomes of infliximab treatment for steroid-refractory ulcerative colitis and related prognostic factors: A single-center retrospective study

Digestion

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Sarcopenia is associated with severe liver fibrosis in patients with non-alcoholic fatty liver disease

Alimentary Pharmacology and Therapeutics

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Early and late neurological complications of liver transplantation in pediatric patients

Pediatric Transplantation

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Lymph node yield after rectal resection in patients treated with neoadjuvant radiation for rectal cancer: A systematic review and meta-analysis

European Journal of Cancer

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The fecal immunochemical test has high accuracy for detecting advanced colorectal neoplasia before age 50

Digestive and Liver Diseases

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Lymphadenectomy with optimum of 29 lymph nodes retrieved associated with improved survival in advanced gastric cancer: A 25,000 patient international database study

Journal of the American College of Surgeons

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A prospective case control study of functional outcomes and related quality of life after colectomy for neoplasia

International Journal of Colorectal Disease

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Association of liver injury from specific drugs, or groups of drugs, with polymorphisms in hla and other genes in a genome-wide association study

Gastroenterology

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