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Background Haemoglobin SC (HbSC) is a common form of sickle cell disease (SCD), especially among individuals of West African ancestry. Persons with HbSC disease suffer from the same clinical complications and reduced quality of life that affect those with sickle cell anaemia (HbSS/Sβ 0 ). Retrospective anecdotal data suggest short-term safety and benefits of hydroxyurea for treating HbSC, yet rigorous prospective data are lacking regarding optimal dosing, clinical and laboratory effects, long-term safety and benefits, and appropriate endpoints to monitor. Prospective Investigation of Variables as Outcomes for Treatment (PIVOT) was designed with three aims: (1) to measure the toxicities of hydroxyurea treatment on laboratory parameters, (2) to assess the effects of hydroxyurea treatment on sickle-related clinical and laboratory parameters, and (3) to identify study endpoints suitable for a future definitive phase III trial of hydroxyurea treatment of HbSC disease. Methods PIVOT is a randomised, placebo-controlled, double blind clinical trial of hydroxyurea. Approximately 120 children and 120 adults ages 5–50 years with HbSC disease will be enrolled, screened for 2 months, and then randomised 1:1 to once-daily oral hydroxyurea or placebo. Study treatment will be prescribed initially at 20 ± 5 mg/kg/day with an opportunity to escalate the dose twice over the first 6 months. After 12 months of blinded study treatment, all participants will be offered open-label hydroxyurea for up to 4 years. Safety outcomes include treatment-related cytopenias, whole blood viscosity, and adverse events. Efficacy outcomes include a variety of laboratory and clinical parameters over the first 12 months of randomised treatment, including changes in haemoglobin and fetal haemoglobin, intracranial arterial velocities measured by transcranial Doppler ultrasound, cerebral oxygenation using near infrared spectrometry, spleen volume and kidney size by ultrasound, proteinuria, and retinal imaging. Exploratory outcomes include functional erythrocyte analyses with ektacytometry for red blood cell deformability and point-of-sickling, patient-reported outcomes using the PROMIS questionnaire, and 6-min walk test. Discussion For children and adults with HbSC disease, PIVOT will determine the safety of hydroxyurea and identify measurable changes in laboratory and clinical parameters, suitable for future prospective testing in a definitive multi-centre phase III clinical trial. Trial registration PACTR, PACTR202108893981080. Registered 24 August 2021, https://pactr.samrc.ac.za

The importance of tryptophan as a precursor for neuroactive compounds has long been acknowledged. The metabolism of tryptophan along the kynurenine pathway and its involvement in mental disorders is an emerging area in psychiatry. We performed a meta-analysis to examine the differences in kynurenine metabolites in major depressive disorder (MDD), bipolar disorder (BD), and schizophrenia (SZ). Electronic databases were searched for studies that assessed metabolites involved in the kynurenine pathway (tryptophan, kynurenine, kynurenic acid, quinolinic acid, 3-hydroxykynurenine, and their associate ratios) in people with MDD, SZ, or BD, compared to controls. We computed the difference in metabolite concentrations between people with MDD, BD, or SZ, and controls, presented as Hedges’ g with 95% confidence intervals. A total of 101 studies with 10,912 participants were included. Tryptophan and kynurenine are decreased across MDD, BD, and SZ; kynurenic acid and the kynurenic acid to quinolinic acid ratio are decreased in mood disorders (i.e., MDD and BD), whereas kynurenic acid is not altered in SZ; kynurenic acid to 3-hydroxykynurenine ratio is decreased in MDD but not SZ. Kynurenic acid to kynurenine ratio is decreased in MDD and SZ, and the kynurenine to tryptophan ratio is increased in MDD and SZ. Our results suggest that there is a shift in the tryptophan metabolism from serotonin to the kynurenine pathway, across these psychiatric disorders. In addition, a differential pattern exists between mood disorders and SZ, with a preferential metabolism of kynurenine to the potentially neurotoxic quinolinic acid instead of the neuroprotective kynurenic acid in mood disorders but not in SZ.

Background Sustainment has been defined as the sustained use or delivery of an intervention in practice following cessation of external implementation support. This review aimed to identify and synthesise factors (barriers and facilitators) that influence the sustainment of interventions (policies, practices, or programmes) in schools and childcare services that address the leading risk factors of chronic disease. Methods Seven electronic databases and relevant reference lists were searched for articles, of any design, published in English, from inception to March 2020. Articles were included if they qualitatively and/or quantitatively reported on school or childcare stakeholders’ (including teachers, principals, administrators, or managers) perceived barriers or facilitators to the sustainment of interventions addressing poor diet/nutrition, physical inactivity, obesity, tobacco smoking, or harmful alcohol use. Two independent reviewers screened texts, and extracted and coded data guided by the Integrated Sustainability Framework, an existing multi-level sustainability-specific framework that assesses factors of sustainment. Results Of the 13,158 articles identified, 31 articles met the inclusion criteria (8 quantitative, 12 qualitative, 10 mixed-methods, and 1 summary article). Overall, 29 articles were undertaken in schools (elementary n =17, middle n =3, secondary n =4, or a combination n =5) and two in childcare settings. The main health behaviours targeted included physical activity ( n =9), diet ( n =3), both diet and physical activity ( n =15), and smoking ( n =4), either independently ( n =1) or combined with other health behaviours ( n =3). Findings suggest that the majority of the 59 barriers and 74 facilitators identified to impact on intervention sustainment were similar across school and childcare settings. Factors predominantly relating to the ‘inner contextual factors’ of the organisation including: availability of facilities or equipment, continued executive or leadership support present, and team cohesion, support, or teamwork were perceived by stakeholders as influential to intervention sustainment. Conclusions Identifying strategies to improve the sustainment of health behaviour interventions in these settings requires a comprehensive understanding of factors that may impede or promote their ongoing delivery. This review identified multi-level factors that can be addressed by strategies to improve the sustainment of such interventions, and suggests how future research might address gaps in the evidence base. Trial registration This review was prospectively registered on PROSPERO: CRD42020127869 , Jan. 2020.

Hydroxyurea increases expression of fetal hemoglobin and decreases clinical complications in children with sickle cell anemia. A trial of a higher dose (30 mg per kg per day) as compared with a standard dose (20 mg per kg) in children in sub-Saharan Africa showed improved outcomes without increased toxicity.

In this multicenter, double-blind trial of convalescent plasma for early, symptomatic SARS-CoV-2 infection, 1225 patients were randomly assigned to receive convalescent plasma or control plasma within 9 days after the onset of symptoms. Significantly fewer recipients of convalescent plasma had progression of Covid-19–associated illness leading to hospitalization.

The protection of headwater streams faces increasing challenges, exemplified by limited global recognition of headwater contributions to watershed resiliency and a recent US Supreme Court decision limiting federal safeguards. Despite accounting for ~77% of global river networks, the lack of adequate headwaters protections is caused, in part, by limited information on their extent and functions—in particular, their flow regimes, which form the foundation for decision-making regarding their protection. Yet, headwater streamflow is challenging to comprehensively measure and model; it is highly variable and sensitive to changes in land use, management and climate. Modelling headwater streamflow to quantify its cumulative contributions to downstream river networks requires an integrative understanding across local hillslope and channel (that is, watershed) processes. Here we begin to address this challenge by proposing a consistent definition for headwater systems and streams, evaluating how headwater streamflow is characterized and advocating for closing gaps in headwater streamflow data collection, modelling and synthesis. Despite their substantial contributions to watershed resilience, headwater streams are becoming increasingly imperilled. This Perspective summarizes the status of headwater streamflow information and proposes guidance for advancing the understanding of headwater hydrology to support better management of these systems.

BackgroundPediatric brain tumors are the leading cause of cancer death in children with an urgent need for innovative therapies. Glypican 2 (GPC2) is a cell surface oncoprotein expressed in neuroblastoma for which targeted immunotherapies have been developed. This work aimed to characterize GPC2 expression in pediatric brain tumors and develop an mRNA CAR T cell approach against this target.MethodsWe investigated GPC2 expression across a cohort of primary pediatric brain tumor samples and cell lines using RNA sequencing, immunohistochemistry, and flow cytometry. To target GPC2 in the brain with adoptive cellular therapies and mitigate potential inflammatory neurotoxicity, we used optimized mRNA to create transient chimeric antigen receptor (CAR) T cells. We developed four mRNA CAR T cell constructs using the highly GPC2-specific fully human D3 single chain variable fragment for preclinical testing.ResultsWe identified high GPC2 expression across multiple pediatric brain tumor types including medulloblastomas, embryonal tumors with multilayered rosettes, other central nervous system embryonal tumors, as well as definable subsets of highly malignant gliomas. We next validated and prioritized CAR configurations using in vitro cytotoxicity assays with GPC2-expressing neuroblastoma cells, where the light-to-heavy single chain variable fragment configurations proved to be superior. We expanded the testing of the two most potent GPC2-directed CAR constructs to GPC2-expressing medulloblastoma and high-grade glioma cell lines, showing significant GPC2-specific cell death in multiple models. Finally, biweekly locoregional delivery of 2–4 million GPC2-directed mRNA CAR T cells induced significant tumor regression in an orthotopic medulloblastoma model and significantly prolonged survival in an aggressive orthotopic thalamic diffuse midline glioma xenograft model. No GPC2-directed CAR T cell related neurologic or systemic toxicity was observed.ConclusionTaken together, these data show that GPC2 is a highly differentially expressed cell surface protein on multiple malignant pediatric brain tumors that can be targeted safely with local delivery of mRNA CAR T cells, laying the framework for the clinical translation of GPC2-directed immunotherapies for pediatric brain tumors.

Being a morning person is a behavioural indicator of a person’s underlying circadian rhythm. Using genome-wide data from 697,828 UK Biobank and 23andMe participants we increase the number of genetic loci associated with being a morning person from 24 to 351. Using data from 85,760 individuals with activity-monitor derived measures of sleep timing we find that the chronotype loci associate with sleep timing: the mean sleep timing of the 5% of individuals carrying the most morningness alleles is 25 min earlier than the 5% carrying the fewest. The loci are enriched for genes involved in circadian regulation, cAMP, glutamate and insulin signalling pathways, and those expressed in the retina, hindbrain, hypothalamus, and pituitary. Using Mendelian Randomisation, we show that being a morning person is causally associated with better mental health but does not affect BMI or risk of Type 2 diabetes. This study offers insights into circadian biology and its links to disease in humans. GWAS have previously found 24 genomic loci associated with chronotype, an individual’s preference for early or late sleep timing. Here, the authors identify 327 additional loci in a sample of 697,828 individuals and further explore the relationships of chronotype with metabolic and psychiatric diseases.

Daytime napping is a common, heritable behavior, but its genetic basis and causal relationship with cardiometabolic health remain unclear. Here, we perform a genome-wide association study of self-reported daytime napping in the UK Biobank ( n  = 452,633) and identify 123 loci of which 61 replicate in the 23andMe research cohort ( n  = 541,333). Findings include missense variants in established drug targets for sleep disorders ( HCRTR1 , HCRTR2 ), genes with roles in arousal ( TRPC6 , PNOC ), and genes suggesting an obesity-hypersomnolence pathway ( PNOC, PATJ ). Association signals are concordant with accelerometer-measured daytime inactivity duration and 33 loci colocalize with loci for other sleep phenotypes. Cluster analysis identifies three distinct clusters of nap-promoting mechanisms with heterogeneous associations with cardiometabolic outcomes. Mendelian randomization shows potential causal links between more frequent daytime napping and higher blood pressure and waist circumference. The genetic basis of daytime napping and the directional effect of daytime napping on cardiometabolic health are unknown. Here, the authors perform a genome-wide association study on self-reported daytime napping in the UK Biobank and Mendelian randomization to explore causal associations.

Large-scale wetland restoration often focuses on repairing the hydrologic connections degraded by anthropogenic modifications. Of these hydrologic connections, groundwater discharge is an important target, as these surface water ecosystem control points are important for thermal stability, among other ecosystem services. However, evaluating the effectiveness of the restoration activities on establishing groundwater discharge connection is often difficult over large areas and inaccessible terrain. Unoccupied aircraft systems (UAS) are now routinely used for collecting aerial imagery and creating digital surface models (DSM). Lightweight thermal infrared (TIR) sensors provide another payload option for generation of sub-meter-resolution aerial TIR orthophotos. This technology allows for the rapid and safe survey of groundwater discharge areas. Aerial TIR water-surface data were collected in March 2019 at Tidmarsh Farms, a former commercial cranberry peatland located in coastal Massachusetts, USA (41°54′17″ N 70°34′17″ W), where stream and wetland restoration actions were completed in 2016. Here, we present a 0.4 km2 georeferenced, temperature-calibrated TIR orthophoto of the area. The image represents a mosaic of nearly 900 TIR images captured by UAS in a single morning with a total flight time of 36 min and is supported by a DSM derived from UAS-visible imagery. The survey was conducted in winter to maximize temperature contrast between relatively warm groundwater and colder ambient surface environment; lower-density groundwater rises above cool surface waters and thus can be imaged by a UAS. The resulting TIR orthomosaic shows fine detail of seepage distribution and downstream influence along the several restored channel forms, which was an objective of the ecological restoration design. The restored stream channel has increased connectivity to peatland groundwater discharge, reducing the ecosystem thermal stressors. Such aerial techniques can be used to guide ecological restoration design and assess post-restoration outcomes, especially in settings where ecosystem structure and function is governed by groundwater and surface water interaction.