Standard Clinical Tests Research Articles

Wearable Thimble-like Device for the Objective Follow-up and Therapy of Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease that affects more than 1 million people worldwide. Since there is no definitive treatment for the disease, the treatment plan for each patient should be updated regularly according to the current level of the disease. There are standard clinical tests, each with its own scoring scale, used to monitor the deterioration of upper and lower extremity functions of MS patients under the supervision of a neurologist and physiotherapist. However, non-objective scoring based on the opinion of the physiotherapist is open to erroneous assessments and may vary from person to person. In addition, clinical tests do not provide detailed information about the functional impairment of the patient. Unfortunately, an objective evaluation system has not yet been implemented all over the world, and the treatment plan is still determined according to the disease in neurological-based disabilities, such as MS, which is of vital importance. personal assessment. To address the aforementioned problem, the design and experimental evaluation of a wearable thimble-like device that can be substituted for the standard clinical tests to assess the follow-up of MS are presented. The device provides the measurement of high sensitivity and opportunity for objective assessment and allows patients of all ages to use it in any desired place during their treatment phase.

Autonomic Cardioregulatory Function Does Not Correlate With Symptom Improvement After Concussion in Children and Adolescents.

Although there is significant variability in the manifestations of persisting post-concussive symptoms (PPCS), autonomic dysfunction has been reported to contribute to PPCS and could serve as a biomarker of recovery. The objective of this study was to evaluate cardiac autonomic reflexes and autonomic function after concussion injury comparing those with prolonged concussion symptoms to those without. This is a case-control study where a non-referred population of concussed children or adolescent participants were enrolled from the Emergency Department (ED) of the Stollery Children's Hospital, a tertiary pediatric hospital in Edmonton, Alberta, Canada. Children and adolescents 8 through <18 years of age who presented with mild traumatic brain injury were diagnosed with concussion. Our study reported concussion symptoms and standardized clinical cardiac autonomic reflex testing at 4 and 12 weeks after injury. Our findings showed that 28 participants with concussion completed the 4-week follow-up questionnaires, and that 17 (61%) were diagnosed with PPCS. Difficulty concentrating, fatigue, noise sensitivity, light sensitivity, and headache were most commonly reported at baseline among those who were later diagnosed with PPCS. The mean change in heart rate (HR) with head-up tilt was 44.2 bpm (standard deviation [SD] 9.1) in the non-PPCS group and 46.6 bpm (SD 14.1) in the PPCS group at 4 weeks and was not significant in the unadjusted (p = 0.2) or adjusted analysis for age and female sex (p = 0.2). Overall, 70% (19/27) had significant orthostatic tachycardia >40 bpm, but PPCS and non-PPCS groups were similar. Similar results were observed among 23 participants at 12-week follow-up. The median maximum decrease in systolic blood pressure (SBP) with head-up tilt was -26.9 mm Hg (interquartile range [IQR] -32.6, -22.3) in the non-PPCS group and -25.1 mm Hg (IQR -32.2, -18.2) in the PPCS group, and was not significantly different in the unadjusted (p = 0.8) or adjusted (p = 0.8) analysis. Overall, 19 of 26 participants (73%) demonstrated orthostatic hypotension (SBP change >20 mm Hg) with no significant difference between the PPCS and non-PPCS groups. Similar results were observed at 12-week follow-up. In conclusion, cardiac autonomic reflex responses are abnormal in most children and adolescents with a concussion injury at 4- and 12-week follow-up and may reflect ongoing autonomic dysfunction. However, autonomic function did not differentiate PPCS, indicating that reported symptoms are not sensitive to autonomic abnormalities.

Machine learning models predict liver steatosis but not liver fibrosis in a prospective cohort study

IntroductionScreening for liver fibrosis continues to rely on laboratory panels and non-invasive tests such as FIB-4-score and transient elastography. In this study, we evaluated the potential of machine learning (ML) methods to predict liver steatosis on abdominal ultrasound and liver fibrosis, namely the intermediate-high risk of advanced fibrosis, in individuals participating in a screening program for colorectal cancer. MethodsWe performed ultrasound on 5834 patients admitted between 2006 and 2020, and transient elastography on a subset of 1240 patients. Steatosis on ultrasound was diagnosed if liver areas showed a significantly increased echogenicity compared to the renal parenchyma. Liver fibrosis was defined as a liver stiffness measurement ≥8 kPa in transient elastography. We evaluated the performance of three algorithms, namely Extreme Gradient Boosting, Feed-Forward neural network and Logistic Regression, deriving the models using data from patients admitted from January 2007 up to January 2016 and prospectively evaluating on the data of patients admitted from January 2016 up to March 2020. We also performed a performance comparison with the standard clinical test based on Fibrosis-4 Index (FIB-4). ResultsThe mean age was 58±9 years with 3036 males (52%). Modelling laboratory parameters, clinical parameters, and data on eight food types/dietary patterns, we achieved high performance in predicting liver steatosis on ultrasound with AUC of 0.87 (95% CI [0.87–0.87]), and moderate performance in predicting liver fibrosis with AUC of 0.75 (95% CI [0.74–0.75]) using XGBoost machine learning algorithm. Patient-reported variables did not significantly improve predictive performance. Gender-specific analyses showed significantly higher performance in males with AUC of 0.74 (95% CI [0.73–0.74]) in comparison to female patients with AUC of 0.66 (95% CI [0.65–0.66]) in prediction of liver fibrosis. This difference was significantly smaller in prediction of steatosis with AUC of 0.85 (95% CI [0.83–0.87]) in female patients, in comparison to male patients with AUC of 0.82 (95% CI [0.80–0.84]). ConclusionML based on point-prevalence laboratory and clinical information predicts liver steatosis with high accuracy and liver fibrosis with moderate accuracy. The observed gender differences suggest the need to develop gender-specific models.

Tests of human auditory temporal resolution: preliminary investigation of ZEST parameters for amplitude modulation detection.

Auditory temporal resolution plays a critical role in the everyday experience of listening to complex acoustic patterns. Amplitude modulation detection thresholds are widely used to measure auditory temporal resolution. In an attempt to develop a standardized clinical test of auditory temporal resolution, we used ZEST (Zippy Estimation by Sequential Testing, a Bayesian threshold estimation procedure, to measure amplitude modulation detection thresholds. ZEST utilizes prior knowledge about a listener's thresholds, as represented by a probability density function of the thresholds, and psychometric functions of the listener's responses. This paper reports a preliminary study in which ZEST parameters that could be used for measurements of amplitude modulation detection thresholds were sought. For this purpose, we created histograms of the detection thresholds for a wide range of modulation frequencies, measured the psychometric functions of amplitude modulation detection, and performed computer simulations of ZEST threshold estimation. The results suggested that, with appropriately-set parameters, ZEST allows for the accurate estimation of amplitude modulation detection thresholds within 20 trials.

Amblyopic stereo vision is efficient but noisy

People with amblyopia demonstrate a reduced ability to judge depth using stereopsis. Our understanding of this deficit is limited, as standard clinical stereo tests may not be suited to give a quantitative account of the residual stereo ability in amblyopia. In this study we used a stereo test designed specifically for that purpose. Participants identified the location of a disparity-defined odd-one-out target within a random-dot display. We tested 29 amblyopic (3 strabismic, 17 anisometropic, 9 mixed) participants and 17 control participants. We obtained stereoacuity thresholds from 59% of our amblyopic participants. There was a factor of two difference between the median stereoacuity of our amblyopic (103 arcsec) and control (56 arcsec) groups. We used the equivalent noise method to evaluate the role of equivalent internal noise and processing efficiency in amblyopic stereopsis. Using the linear amplifier model (LAM), we determined the threshold difference was due to a greater equivalent internal noise in the amblyopic group (238 vs 135 arcsec), with no significant difference in processing efficiency. A multiple linear regression determined 56% of the stereoacuity variance within the amblyopic group was predicted by the two LAM parameters, with equivalent internal noise predicting 46% alone. Analysis of control group data aligned with our previous work, finding that trade-offs between equivalent internal noise and efficiency play a greater role. Our results allow a better understanding of what is limiting amblyopic performance in our task. We find this to be a reduced quality of disparity signals in the input to the task-specific processing.

ARTERIAL STIFFNESS ESTIMATED BY BRACHIAL OSCILLOMETRY PREDICTS PROGRESSION TO HYPERTENSION IN PATIENTS WITH NORMAL AMBULATORY BLOOD PRESSURE

Objective: There is growing evidence that arterial stiffness can precede hypertension (HTN). This study aimed to assess the predictive value of Pulse Wave Velocity, estimated by brachial oscillometry (ePWV), for incident HTN in patients with initially normal ambulatory BP measurement (ABPM) after one year of follow-up. Design and method: This retrospective, observational, longitudinal study included all consecutive patients referred to a HTN Unit with suspected naïve HTN, without prior pharmacological treatment. EVA was defined according to ePWV exceeding the 90th percentile of its age group (Mobil-O-Graph, IEM®). Incident HTN was defined as ABPM at follow-up &gt; 130/80 mmHg or prescription of antihypertensive medication. Standard clinical tests and ABPM were performed at baseline and after 12 months. Results: 223 consecutive patients with ABPM &lt;130/80 mmHg entered the study, with 155 women (69.5%), a mean age of 47.9 years (±13.5), mean office BP of 128/73 (±13/8), mean ABPM of 118/73 (±7/5) mmHg and mean estimated PWV of 7.74 m/s (±1.7). At baseline, 51.1% of patients showed EVA. At follow-up, after a mean time of 1,1 years, 114 participants presented elevated ABPM. After adjustment for age, gender and ambulatory BP, presence of EVA at baseline was associated with progression to HTN at follow-up (OR:2,5;IC:1,4-4,6;p = 0.003). Furthermore, the pattern of PWV-EVA and incident HTA according to age were superimposable (Image). Arterial stiffness defined as ePWV &gt; 10 m/s was also significantly associated with incident HTN, but showed a completely different distribution in age compared with incident HTN. Of note, arterial stiffness at follow-up was mainly determined by EVA at baseline (OR:6.1;IC:3.2-11.6;p = 0.001), but not by BP traits. Conclusions: Arterial damage, characterized as early vascular aging according to estimated PWV by brachial oscillometry, doubles the probability of sustained HTN one year after initial assessment in naïve patients with normal ABPM at baseline, independently of ambulatory and or office blood pressure at baseline. On the other hand, the main determinant of arterial stiffness at follow-up was elevated ePWV at baseline, but not blood pressure traits.

Advantages of routine next-generation sequencing over standard genetic testing in the amyotrophic lateral sclerosis clinic.

Next-generation sequencing has enhanced our understanding of amyotrophic lateral sclerosis (ALS) and its genetic epidemiology. Outside the research setting, testing is often restricted to those who report a family history. The aim of this study was to explore the added benefit of offering routine genetic testing to all patients in a regional ALS centre. C9ORF72 expansion testing and exome sequencing was offered to consecutive patients (150 with ALS and 12 with primary lateral sclerosis [PLS]) attending the Oxford Motor Neuron Disease Clinic within a defined time period. A total of 17 (11.3%) highly penetrant pathogenic variants in C9ORF72, SOD1, TARDBP, FUS and TBK1 were detected, of which 10 were also found through standard clinical genetic testing pathways. The systematic approach resulted in five additional diagnoses of a C9ORF72 expansion (number needed to test [NNT] = 28), and two further missense variants in TARDBP and SOD1 (NNT = 69). Additionally, 3 patients were found to carry pathogenic risk variants in NEK1, and 13 patients harboured common missense variants in CFAP410 and KIF5A, also associated with an increased risk of ALS. We report two novel non-coding loss-of-function splice variants in TBK1 and OPTN. No relevant variants were found in the PLS patients. Patients were offered double-blinded participation, but >80% requested disclosure of the results. This study provides evidence that expanding genetic testing to all patients with a clinical diagnosis of ALS enhances the potential for recruitment to clinical trials, but will have direct resource implications for genetic counselling.

Insights into anti-tumor immunity via the polyomavirus shared across human Merkel cell carcinomas.

Understanding and augmenting cancer-specific immunity is impeded by the fact that most tumors are driven by patient-specific mutations that encode unique antigenic epitopes. The shared antigens in virus-driven tumors can help overcome this limitation. Merkel cell carcinoma (MCC) is a particularly interesting tumor immunity model because (1) 80% of cases are driven by Merkel cell polyomavirus (MCPyV) oncoproteins that must be continually expressed for tumor survival; (2) MCPyV oncoproteins are only ~400 amino acids in length and are essentially invariant between tumors; (3) MCPyV-specific T cell responses are robust and strongly linked to patient outcomes; (4) anti-MCPyV antibodies reliably increase with MCC recurrence, forming the basis of a standard clinical surveillance test; and (5) MCC has one of the highest response rates to PD-1 pathway blockade among all solid cancers. Leveraging these well-defined viral oncoproteins, a set of tools that includes over 20 peptide-MHC class I tetramers has been developed to facilitate the study of anti-tumor immunity across MCC patients. Additionally, the highly immunogenic nature of MCPyV oncoproteins forces MCC tumors to develop robust immune evasion mechanisms to survive. Indeed, several immune evasion mechanisms are active in MCC, including transcriptional downregulation of MHC expression by tumor cells and upregulation of inhibitory molecules including PD-L1 and immunosuppressive cytokines. About half of patients with advanced MCC do not persistently benefit from PD-1 pathway blockade. Herein, we (1) summarize the lessons learned from studying the anti-tumor T cell response to virus-positive MCC; (2) review immune evasion mechanisms in MCC; (3) review mechanisms of resistance to immune-based therapies in MCC and other cancers; and (4) discuss how recently developed tools can be used to address open questions in cancer immunotherapy. We believe detailed investigation of this model cancer will provide insight into tumor immunity that will likely also be applicable to more common cancers without shared tumor antigens.

Elevated Cytokine Levels in Gingival Crevicular Fluid of Teeth with Apical Periodontitis

IntroductionBiomarkers assayed from gingival crevicular fluid (GCF) are a potential tool for endodontic diagnosis and for monitoring treatment response. This cross-sectional study measured cytokines in GCF from teeth with apical periodontitis and evaluated their relationship with preoperative pain and other clinical findings. MethodsParticipants presenting for root-end resection surgery due to apical periodontitis diagnosis (n = 56) underwent standardized clinical testing and completed preoperative questionnaires. GCF from diseased and control teeth were collected, processed, and analyzed. Mann-Whitney U and Wilcoxon tests were used to examine the cytokine levels in diseased compared to healthy control teeth. We also assessed the relationship of cytokine levels with clinical findings. ResultsInterleukins (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, interferon-γ, and tumor necrosis factor-⍺ (TNF-⍺) were detected in GCF. TNF-⍺ levels were significantly higher in GCF collected from diseased versus control teeth (P = .02) and increased IL-1β levels in diseased teeth were detected (P = .06). Lower IL-10 levels were observed in teeth with a sinus tract and/or swelling compared to teeth without a sinus tract and/or swelling (P = .08). Cytokine levels did not clearly relate to the presence of pain. ConclusionsElevated levels of proinflammatory cytokines, including TNF-⍺ and IL1- β, were detected in GCF from diseased teeth compared to the healthy controls. Additional studies are needed to further investigate the utility of these biomarkers for objectively evaluating periradicular pathology.

Optical Genome Mapping Reveals and Characterizes Recurrent Aberrations and New Fusion Genes in Adult ALL

(1) Background: In acute lymphoblastic leukemia (ALL) the genetic characterization remains challenging. Due to the genetic heterogeneity of mutations in adult patients, only a small proportion of aberrations can be analyzed with standard routine diagnostics. Optical genome mapping (OGM) has recently opened up new possibilities for the characterization of structural variants on a genome-wide level, thus enabling simultaneous analysis for a broad spectrum of genetic aberrations. (2) Methods: 11 adult ALL patients were examined using OGM. (3) Results: Genetic results obtained by karyotyping and FISH were confirmed by OGM for all patients. Karyotype was redefined, and additional genetic information was obtained in 82% (9/11) of samples by OGM, previously not diagnosed by standard of care. Besides gross-structural chromosome rearrangements, e.g., ring chromosome 9 and putative isodicentric chromosome 8q, deletions in CDKN2A/2B were detected in 7/11 patients, defining an approx. 20 kb minimum region of overlap, including an alternative exon 1 of the CDKN2A gene. The results further confirm recurrent ALL aberrations (e.g., PAX5, ETV6, VPREB1, IKZF1). (4) Conclusions: Genome-wide OGM analysis enables a broad genetic characterization in adult ALL patients in one single workup compared to standard clinical testing, facilitating a detailed genetic diagnosis, risk-stratification, and target-directed treatment strategies.

Accuracy of Preoperative Ultrasonographic Airway Assessment in Predicting Difficult Laryngoscopies in Adult Patients.

Background and objectives Presently, neck ultrasonography is used as a tool to predict a difficult airway. There are no standardized ultrasonographic criteria that help to predict a difficult airway. This study aims to ultrasonographically assess the anterior neck soft tissue thickness preoperatively based on two parameters-the minimal distance from the hyoid bone to skin (DSHB) and the distance from the skin to the epiglottis midway between the hyoid bone and thyroid cartilage (DSEM)-and find out whether these parameters can predict a difficult airway in adults by correlating with the Cormack-Lehane (CL) grading. Background and objectives After obtaining ethical committee clearance and patient consent, we conducted this study on 96 patients aged between 18 and 60 years, belonging to American Society of Anesthesiologists (ASA) classes one and two, who were admitted for elective surgery under general anesthesia with endotracheal intubation to RL Jalappa Hospital and Research Centre, Tamaka, Kolar, from January 2020 to May 2021. The exclusion criteria were patients with anticipated difficult airway cases, such as obesity, pregnancy, head and neck anatomical pathologies, maxillofacial anomalies, and edentulous patients. The sonography of the airway was first performed preoperatively by an anesthesiologist along with standard clinical tests such as Mallampati (MP) grading. The sonography included two parameters: DSHB and DSEM. The patients were later classified as having easy or difficult laryngoscopy based on USG criteria from the available literature. A DSHB value of greater than 0.66 cm was predicted to be a difficult airway, and less than 0.66 cm was predicted to be easy. A DSEM value greater than 2.03 cm was predicted to be a difficult airway, and less than 2.03 cm was predicted to be easy. After induction of anesthesia, another experienced anesthesiologist performed direct laryngoscopy in the sniffing position with an appropriate-sized Macintosh blade and CL grades. CL grades I and II were considered to be easy laryngoscopies. The quantitative data were presented by mean SD and confidence interval (CI). The qualitative data were presented in percentages, and p-values less than 0.05 were considered statistically significant. To determine the discriminative power of individual tests, the receiver operating characteristic curve and the area under the curve with a 95% confidence interval was noted. Results The two USG parameters DSHB and DSEM may be used to predict difficult laryngoscopy in adult patients, as both have very strong statistical significance. Of the two parameters, DSHB seems to have a better diagnostic value for predicting a difficult airway in our study, as supported by thearea under the curve (AUC) of 97.4% compared to DSEM with an AUC of 88.8%. DSHB has better sensitivity (100%), and DSEM has better specificity (89.77%). Conclusion Our study showed that DSHB and DSEM may aid in predicting difficult laryngoscopies, as a strong statistical significance was present between sonographic measurements and CL grading. DSHB also appeared to have a better diagnostic value for predicting a difficult airway.

Psychophysical performance differences associated with auditory spatial attention in older listeners with and without hearing loss

In a busy listening environment with multiple speakers, even normal-hearing listeners may face difficulties in understanding speech (i.e., “the cocktail party problem”). Individual factors related to bottom-up and/or top-down processing difficulties may be associated with the listener’s ability to attend to speech, a key component in navigating complex acoustic environments. The present study tested listeners on a battery of psychophysical measures and compared listener performance to cortical measures (EEG) of spatial-change tuning and auditory spatial attention. The behavioral tests measured both perceptual and cognitive performance and included: frequency modulation detection, spectro-temporal modulation sensitivity, spatial release from masking, temporal gap detection, auditory and non-auditorysustained attention, and visuo-spatial problem solving. The EEG paradigm tested the listener’s ability to attend to moving speech in quiet or background babble in the free field. Older listeners with and without hearing loss (n = 20 per group) demonstrated wide individual performance for some measures and significant correlations between behavioral thresholds and cortical responses, consistent with a more refined view of age-related hearing loss and a need for a more holistic approach in diagnoses for individuals beyond standard clinical tests. [Work supported by NIH R21DC017832.]

On the kinematics of the cross body abduction and hand behind the back tests to assess osteoarthritis of the acromioclavicular joint

Background: Osteoarthritis of the acromioclavicular joint is one of the most common sources of shoulder pain. One of the current standard clinical physical examination tests is the cross body adduction test which has been shown to signal the presence of osteoarthritis. Another test referred to as the hand behind the back test has been described to provide a more accurate diagnosis than the CBA test for some patients. Through this work, both the CBA and the HBB tests were modeled in order to determine if there is merit for the HBB test to be used as a diagnostic tool for clinicians. Methods: Both tests were modeled using the zygote solid 3D 50th percentile male human anatomy model and MSC-ADAMS Software to compile and run the simulations. Within MSC-ADAMS the bones were outfitted with joints. During simulation, the bones were moved from the anatomical position to the final position for each test and the corresponding minimum distances between the bones at the acromioclavicular joint were then determined. Results: It was found that the distance between the acromioclavicular joint articulating surfaces decreased by 0.3 mm from the anatomical position during the CBA test and by 1.65 mm from the anatomical position during the HBB. This shows that the minimum space decreased from the anatomical position by more than 5 folds during the HBB test than during the CBA test. Conclusions: These results indicate that the HBB test may be a better diagnostic test due to the greater stress and irritation it places upon the acromioclavicular joint.

Real world validation of activity recognition algorithm and development of novel behavioral biomarkers of falls in aged control and movement disorder patients.

The use of wearable sensors in movement disorder patients such as Parkinson's disease (PD) and normal pressure hydrocephalus (NPH) is becoming more widespread, but most studies are limited to characterizing general aspects of mobility using smartphones. There is a need to accurately identify specific activities at home in order to properly evaluate gait and balance at home, where most falls occur. We developed an activity recognition algorithm to classify multiple daily living activities including high fall risk activities such as sit to stand transfers, turns and near-falls using data from 5 inertial sensors placed on the chest, upper-legs and lower-legs of the subjects. The algorithm is then verified with ground truth by collecting video footage of our patients wearing the sensors at home. Our activity recognition algorithm showed >95% sensitivity in detection of activities. Extracted features from our home monitoring system showed significantly better correlation (~69%) with prospectively measured fall frequency of our subjects compared to the standard clinical tests (~30%) or other quantitative gait metrics used in past studies when attempting to predict future falls over 1 year of prospective follow-up. Although detecting near-falls at home is difficult, our proposed model suggests that near-fall frequency is the most predictive criterion in fall detection through correlation analysis and fitting regression models.

Control of tissue oxygenation by S-nitrosohemoglobin in human subjects

S-Nitrosohemoglobin (SNO-Hb) is unique among vasodilators in coupling blood flow to tissue oxygen requirements, thus fulfilling an essential function of the microcirculation. However, this essential physiology has not been tested clinically. Reactive hyperemia following limb ischemia/occlusion is a standard clinical test of microcirculatory function, which has been ascribed to endothelial nitric oxide (NO). However, endothelial NO does not control blood flow governing tissue oxygenation, presenting a major quandary. Here we show in mice and humans that reactive hyperemic responses (i.e., reoxygenation rates following brief ischemia/occlusion) are in fact dependent on SNO-Hb. First, mice deficient in SNO-Hb (i.e., carrying C93A mutant Hb refractory to S-nitrosylation) showed blunted muscle reoxygenation rates and persistent limb ischemia during reactive hyperemia testing. Second, in a diverse group of humans-including healthy subjects and patients with various microcirculatory disorders-strong correlations were found between limb reoxygenation rates following occlusion and both arterial SNO-Hb levels (n = 25; P= 0.042) and SNO-Hb/total HbNO ratios (n = 25; P= 0.009). Secondary analyses showed that patients with peripheral artery disease had significantly reduced SNO-Hb levels and blunted limb reoxygenation rates compared with healthy controls (n = 8 to 11/group; P< 0.05). Low SNO-Hb levels were also observed in sickle cell disease, where occlusive hyperemic testing was deemed contraindicated. Altogether, our findings provide both genetic and clinical support for the role of red blood cells in a standard test of microvascular function. Our results also suggest that SNO-Hb is a biomarker and mediator of blood flow governing tissue oxygenation. Thus, increases in SNO-Hb may improve tissue oxygenation in patients with microcirculatory disorders.

Investigating Visual Perception Impairments through Serious Games and Eye Tracking to Anticipate Handwriting Difficulties.

Dysgraphia is a learning disability that causes handwritten production below expectations. Its diagnosis is delayed until the completion of handwriting development. To allow a preventive training program, abilities not directly related to handwriting should be evaluated, and one of them is visual perception. To investigate the role of visual perception in handwriting skills, we gamified standard clinical visual perception tests to be played while wearing an eye tracker at three difficulty levels. Then, we identified children at risk of dysgraphia through the means of a handwriting speed test. Five machine learning models were constructed to predict if the child was at risk, using the CatBoost algorithm with Nested Cross-Validation, with combinations of game performance, eye-tracking, and drawing data as predictors. A total of 53 children participated in the study. The machine learning models obtained good results, particularly with game performances as predictors (F1 score: 0.77 train, 0.71 test). SHAP explainer was used to identify the most impactful features. The game reached an excellent usability score (89.4 ± 9.6). These results are promising to suggest a new tool for dysgraphia early screening based on visual perception skills.

Oculomotor Findings in Videonystagmography across the Lifespan.

When performing oculomotor testing during standard videonystagmography (VNG), the vestibular system is not actively stimulated. Therefore, responses are generated from the cerebellum, brainstem, and oculomotor tract. Many patients seen for vestibular testing fall outside of the standard age norms, making it difficult to determine whether an abnormal finding is due to age or oculomotor dysfunction. The purpose of this study was to further evaluate the effect of age on a standard clinical VNG oculomotor test battery consisting of saccades, smooth pursuit, and optokinetic (OPK) testing. This is a cross-sectional, between-group prospective study comparing oculomotor tests between age groups. Twenty-one older adults between the ages of 60 and 90 years with no history of central or peripheral vestibular dysfunction were included in the study. Previously collected data from 29 children aged 4 to 6 years and 33 adults aged 20 to 60 years were also included. Participants completed oculomotor testing using infrared goggles consisting of saccades, smooth pursuit, and OPK. Statistical analyses were completed using multivariate analysis of variance and analysis of variance and follow-up analysis when indicated. Significant group differences were noted for saccade latency and speed, smooth pursuit gain, and OPK gain and speed. Children and older adults demonstrated longer saccade latencies compared with the controls, and older adults exhibited slower saccade speed than the controls and children. These results also indicated that smooth pursuit gain was reduced for children and older adults compared with controls, and gain decreased across all groups as frequency increased. Analyses of OPK results indicated older adults had reduced gain and speed compared with the children and control group. The findings of prolonged saccade latencies and reduced smooth pursuit gain in both children and older adults suggest possible cerebellar rather than attentional effects. However, other findings such as reduced saccade speed and reduced OPK gain were noted only in the older adults, which suggests oculomotor degeneration and/or insufficient coverage of the visual field during testing, respectively. These results also indicate the importance of age-specific normative data for use in clinical oculomotor testing.

Identification of HER2+ malignant cells in gastric tumors from single-cell RNAseq data.

417 Background: Gastric cancer is the 4th leading cause of cancer death worldwide with high incidence in East Asia. Despite recent developments in treatment options, gastric cancer survival rate remains low, partially attribute to tumor heterogeneity. Here we performed a comprehensive single cell analysis of malignant cells from gastric tumor samples. In addition to characterizing heterogenous transcriptional patterns, we developed a framework to identify HER2+ malignant cells, which may complement standard diagnostics for treatment decisions. Methods: Published and in-house generated 10x Genomics single cell RNAseq data in tumor and normal samples from gastric cancer patients were aggregated, including 64 tumor samples and 27 pre-cancerous samples and 12 adjacent normal samples. The R package Seurat (version 4.0) was applied for data QC and downstream analysis. High quality cells were clustered using highly variable genes and cell types were annotated by curated marker genes. To identify malignant epithelial cells, a gastric cancer signature was derived using matched tumor and normal samples from TCGA gastric cancer patients. Gastric tumor samples were also leveraged to develop a HER2 signature and TCGA breast tumor samples were used to validate the signature. HER2+ malignant cells were identified by re-clustering malignant epithelial cells using the HER2 signature. Results: 345,361 high-quality single cells were profiled, representing major cell types within tumor microenvironment. Among 59,861 epithelial cells, 22,770 malignant cells were identified with high expression of a gastric cancer signature. Copy number alterations (aneuploid) were highly enriched in inferred malignant cells compared with non-malignant cells (48.6% vs 1.4%, p&lt;2.2×10-16, Fisher’s exact test). Further clustering analysis identified 10 subclusters with divergent expression of cancer oncogenic pathways, highlighting the vast heterogeneity of tumor origin. A Her2 amplification signature was derived using TCGA gastric cancer cohort (AUC=0.99) and validated in breast cancer cohort (AUC=0.93). Applying this signature to malignant cells, HER2+ cells were identified in a majority of tumors, with various proportions. In an independent data set, the percentage of HER2+ malignant cells is highly concordant with clinical HER2+ status, indicating the potential use of single cell data to supplement HER2+ clinical testing for treatment selection. Conclusions: This meta-analysis of single cell RNAseq data provides a comprehensive snapshot of tumor heterogeneity in gastric cancers, with aberrance in multiple oncogenic pathways observed in patients. The HER2+ cell classifier developed here holds the potential to complement standard clinical testing and enable personalized medicine, warranting further validation.

Carbon Dioxide Potentiates Flucytosine Susceptibility in Cryptococcus neoformans.

Cryptococcal meningoencephalitis remains a global health threat with limited treatment options. Currently, the most effective treatment regimens are based on a combination therapy of flucytosine with either amphotericin B or fluconazole. Slow but steady progress is being made toward universal access to flucytosine-based therapies. The broadening access to flucytosine combination therapies will be accompanied by the need for microbiological methods that reliably determine strain susceptibility. This is especially true considering that flucytosine susceptibility can vary widely across clinical isolates. Identifying culture conditions that best represent the host environment are likely optimal and may even be required for accurately determining in vivo flucytosine susceptibility. Here, we report that culture conditions incorporating host-like concentrations of carbon dioxide (CO2) potentiated flucytosine susceptibilities across clinical isolates (10 of 11) that exhibited a range of MIC values under ambient growth conditions (2 to 8 μg/mL) by standard Clinical and Laboratory Standards Institute susceptibility testing. CO2 induced a dose-dependent increase in flucytosine susceptibility between 2- and 8-fold over standard conditions. The CO2-dependent increase in flucytosine susceptibility did not correspond to an increase in fluorouracil susceptibility, indicating a central role for flucytosine uptake through the cytosine permease in the presence of host-like CO2 concentrations. Indeed, the expression of the cytosine permease gene (FCY2) was induced 18- to 60-fold in the mouse lung environment. Therefore, the activity of flucytosine is likely to be very dependent upon host environment and may not be well represented by standard in vitro susceptibility testing. IMPORTANCE Cryptococcus neoformans causes life-threatening infections of the brain. The most effective treatment regimens are based on flucytosine-based combination therapy, which has led to increasingly successful broadening of access to flucytosine globally. Wider use of flucytosine-based therapies for cryptococcal infections will require the ability to reliably determine clinical isolate susceptibilities. We showed that host-like carbon dioxide stress affected flucytosine susceptibility, and this likely occurred through flucytosine uptake. We further showed that the gene encoding the permease, FCY2, and that is responsible for flucytosine uptake was strongly induced during cryptococcal infection. Our data provide insights into the distinctions between the activity of flucytosine in the host environment and during in vitro susceptibility testing.

Continuing a search for a diagnosis: the impact of adolescence and family dynamics

The “diagnostic odyssey” describes the process those with undiagnosed conditions undergo to identify a diagnosis. Throughout this process, families of children with undiagnosed conditions have multiple opportunities to decide whether to continue or stop their search for a diagnosis and accept the lack of a diagnostic label. Previous studies identified factors motivating a family to begin searching, but there is limited information about the decision-making process in a prolonged search and how the affected child impacts a family’s decision. This study aimed to understand how families of children with undiagnosed diseases decide whether to continue to pursue a diagnosis after standard clinical testing has failed. Parents who applied to the Undiagnosed Disease Network (UDN) at the National Institutes of Health (NIH) were recruited to participate in semi-structured interviews. The 2015 Supportive Care Needs model by Pelenstov, which defines critical needs in families with rare/undiagnosed diseases, provided a framework for interview guide development and transcript analysis (Pelentsov et al in Disabil Health J 8(4):475–491, 2015. https://doi.org/10.1016/J.DHJO.2015.03.009). A deductive, iterative coding approach was used to identify common unifying themes. Fourteen parents from 13 families were interviewed. The average child’s age was 11 years (range 3–18) and an average 63% of their life had been spent searching for a diagnosis. Our analysis found that alignment or misalignment of parent and child needs impact the trajectory of the diagnostic search. When needs and desires align, reevaluation of a decision to pursue a diagnosis is limited. However, when there is conflict between parent and child desires, there is reevaluation, and often a pause, in the search. This tension is exacerbated when children are adolescents and attempting to balance their dependence on parents for medical care with a natural desire for independence. Our results provide novel insights into the roles of adolescents in the diagnostic odyssey. The tension between desired and realistic developmental outcomes for parents and adolescents impacts if, and how, the search for a diagnosis progresses.