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Concept: Work in progress


The importance of hemoglobin A2 (HbA2) as an indicator of the presence of β-thalassemia was established many years ago. However, clinical application of recommended HbA2 cut off values is often hampered due to poor equivalence of HbA2 results among methods and laboratories. Thus, the IFCC Standardization program for HbA2 was initiated in 2004 with the goal of achieving a complete reference system for this measurand. HbA2 standardization efforts are still in progress, including the development of a higher-order HbA2 reference measurement procedure and the preparation of a certified reference material in collaboration with the IRMM. Here, we review the past, present and future of HbA2 standardization and describe the current status of HbA2 testing.

Concepts: Present, Time, Future, Work in progress, The Current, Past, Certified reference materials, Standards


The analysis of geographic variations has spurred arguments that area of residence determines access to and quality of healthcare. In this paper we argue that unwarranted geographic variations can be traced back to actions of individual patients and their healthcare providers (doctors, hospitals). These actors interact in a complicated web of shared responsibilities. Designing effective interventions to reduce unwarranted geographic variations may therefore depend on methods to identify these interactions and communities of providers with a shared accountability. In the US, Canada, and Germany, routine data have been used to identify self-organized informal or virtual networks of physicians and hospitals, so-called patient-sharing networks (PSNs). This is an emerging field of analysis. We attempt to provide a brief report on the state of work in progress. It can be shown that variation between PSNs in a given area is effectively greater than variation between regions. While this suggests that reducing unwarranted variation needs to start at the level of PSN, methods to identify PSNs still vary widely. We compare epidemiological approaches and approaches based on graph theory and social network analysis. We also present some preliminary findings of exploratory analyses based on comprehensive claims data of physician practices in Germany. Defining PSNs based on usual provider relationships helps to create distinctive patient populations while PSNs may not be mutually exclusive. Social network analysis, on the other hand, appears better equipped to differentiate between provider communities with stronger and weaker ties; it does not yield distinctive patient populations. To achieve accountability and to support change management, analytic methods to describe PSNs still need refinement. There are first projects in Germany which use PSNs as an intervention platform in order to achieve improved cooperation and reduce unwarranted variation in their care processes.

Concepts: Health care provider, Patient, Hospital, Sociology, Physician, Work in progress, Social network, Network theory


Zika virus can be transmitted by transfusion, but the harm caused to recipients is not clear in most cases. It is very likely that the virus could also be transmitted by transplanted organs. Sensitivity to the risk from transfusion is elevated by consideration of possible severe neurologic damage in fetuses. Strategies for dealing with transfusion risk vary with the presence of Zika in the region. In nonendemic areas, risks can be reduced by excluding donors who have exposure through travel or sexual contact with someone at risk. In both endemic and nonendemic areas, the risk can be further reduced by nucleic acid testing of donors, or pathogen reduction of platelet and plasma products. The real risk to the population depends on the frequency of infection as well as the efficacy of these interventions. The interventions chosen will depend on the risk assessment for any situation; in the United States at this time, a combination of travel deferrals, testing, and, to a lesser extent, pathogen reduction is being used, but universal testing of US blood donors under investigational use has been mandated by the US Food and Drug Administration, beginning with states most at risk of local transmission. Canada is largely using travel deferrals. A precautionary approach may be taken; however, a formal decision-making framework has been suggested. The situation globally is clearly very fluid, as the epidemic continues to spread and we continue to learn how to best protect recipients of blood and transplants.

Concepts: Immune system, Blood, Risk, Nitrogen, Nucleic acid, Risk management, Work in progress, Risk assessment


Decades of animal and human neuroimaging research have identified distinct, but overlapping, striatal zones, which are interconnected with separable corticostriatal circuits, and are crucial for the organization of functional systems. Despite continuous efforts to subdivide the human striatum based on anatomical and resting-state functional connectivity, characterizing the different psychological processes related to each zone remains a work in progress. Using an unbiased, data-driven approach, we analyzed large-scale coactivation data from 5,809 human imaging studies. We (i) identified five distinct striatal zones that exhibited discrete patterns of coactivation with cortical brain regions across distinct psychological processes and (ii) identified the different psychological processes associated with each zone. We found that the reported pattern of cortical activation reliably predicted which striatal zone was most strongly activated. Critically, activation in each functional zone could be associated with distinct psychological processes directly, rather than inferred indirectly from psychological functions attributed to associated cortices. Consistent with well-established findings, we found an association of the ventral striatum (VS) with reward processing. Confirming less well-established findings, the VS and adjacent anterior caudate were associated with evaluating the value of rewards and actions, respectively. Furthermore, our results confirmed a sometimes overlooked specialization of the posterior caudate nucleus for executive functions, often considered the exclusive domain of frontoparietal cortical circuits. Our findings provide a precise functional map of regional specialization within the human striatum, both in terms of the differential cortical regions and psychological functions associated with each striatal zone.

Concepts: Cerebral cortex, Cerebrum, Substantia nigra, Work in progress, Striatum, Category theory, Putamen, Caudate nucleus


The reliability and validity of traditional taxonomies are limited by arbitrary boundaries between psychopathology and normality, often unclear boundaries between disorders, frequent disorder co-occurrence, heterogeneity within disorders, and diagnostic instability. These taxonomies went beyond evidence available on the structure of psychopathology and were shaped by a variety of other considerations, which may explain the aforementioned shortcomings. The Hierarchical Taxonomy Of Psychopathology (HiTOP) model has emerged as a research effort to address these problems. It constructs psychopathological syndromes and their components/subtypes based on the observed covariation of symptoms, grouping related symptoms together and thus reducing heterogeneity. It also combines co-occurring syndromes into spectra, thereby mapping out comorbidity. Moreover, it characterizes these phenomena dimensionally, which addresses boundary problems and diagnostic instability. Here, we review the development of the HiTOP and the relevant evidence. The new classification already covers most forms of psychopathology. Dimensional measures have been developed to assess many of the identified components, syndromes, and spectra. Several domains of this model are ready for clinical and research applications. The HiTOP promises to improve research and clinical practice by addressing the aforementioned shortcomings of traditional nosologies. It also provides an effective way to summarize and convey information on risk factors, etiology, pathophysiology, phenomenology, illness course, and treatment response. This can greatly improve the utility of the diagnosis of mental disorders. The new classification remains a work in progress. However, it is developing rapidly and is poised to advance mental health research and care significantly as the relevant science matures. (PsycINFO Database Record

Concepts: Psychology, The Canon of Medicine, Avicenna, Taxonomy, Greek loanwords, Mental disorder, Work in progress, Psychiatry


Cervical arterial dissection (CAD) is a common cause of stroke in young people under 55 years. It can occur spontaneously or subsequent to minor trauma or infection. The incidence is difficult to determine accurately as not all CAD progress to stroke. CAD is the most catastrophic adverse event associated with cervical manipulative therapy but it is rare. Early features of CAD can mimic a painful musculoskeletal presentation and a patient may present for treatment of neck pain and headache with a dissection in progress. Whether the manipulative technique is responsible for dissection or whether the diagnosis of CAD has been missed is unclear. Identification of individuals at risk, or early recognition of CAD could help expedite medical intervention and avoid inappropriate treatment.

Concepts: Greek loanwords, Pain, Acupuncture, Aortic dissection, Work in progress, Suffering, Vertebral artery dissection, Carotid artery dissection


The development of the cytotoxic T-lymphocyte-associated protein 4 inhibitor ipilimumab and its approval in 2011 for the treatment of metastatic melanoma has heralded a new era in immuno-oncology. Subsequently, novel agents against the programmed death receptor 1 (PD-1)/programmed death receptor ligand 1 (PD-L1) axis have shown significant activity in melanoma and a variety of other tumor types. Pembrolizumab was the first anti-PD-1 antibody to be approved by the US Food and Drug Administration for the treatment of patients with unresectable or metastatic melanoma with disease progression following ipilimumab, and if BRAF (V600) mutation positive, a BRAF inhibitor. Pembrolizumab has also received breakthrough status for the treatment of EGFR mutation-negative, ALK rearrangement-negative non-small cell lung cancer (NSCLC) that has progressed on or following platinum-based chemotherapy. There remain a number of pivotal trials in progress to further evaluate the optimal use of pembrolizumab alone and in combination for melanoma, NSCLC, and other tumor types. In this article, we review the efficacy and toxicity profile of pembrolizumab and evaluate its future development.

Concepts: Cancer, Metastasis, Oncology, Lung cancer, Non-small cell lung carcinoma, Receptor, Melanoma, Work in progress


While methods for genetic species delimitation have noticeably improved in the last decade, this remains a work in progress. Ideally, model based approaches should be applied and considered jointly with other lines of evidence, primarily morphology and geography, in an integrative taxonomy framework. Deep phylogeographic divergences have been reported for several species of Carlia skinks, but only for some eastern taxa have species boundaries been formally tested. The present study does this and revises the taxonomy for two species from northern Australia, Carlia johnstonei and C. triacantha. We introduce an approach that is based on the recently published method StarBEAST2, which uses multilocus data to explore the support for alternative species delimitation hypotheses using Bayes Factors (BFD). We apply this method, jointly with two other multispecies coalescent methods, using an extensive (from 2,163 exons) data set along with measures of 11 morphological characters. We use this integrated approach to evaluate two new candidate species previously revealed in phylogeographic analyses of rainbow skinks (genus Carlia) in Western Australia. The results based on BFD StarBEAST2, BFD* SNAPP and BPP genetic delimitation, together with morphology, support each of the four recently identified Carlia lineages as separate species. The BFD StarBEAST2 approach yielded results highly congruent with those from BFD* SNAPP and BPP. This supports use of the robust multilocus multispecies coalescent StarBEAST2 method for species delimitation, which does not require a priori resolved species or gene trees. Compared to the situation in C. triacantha, morphological divergence was greater between the two lineages within Kimberley endemic C. johnstonei, which also had deeper divergent histories. This congruence supports recognition of two species within C. johnstonei. Nevertheless, the combined evidence also supports recognition of two taxa within the more widespread C. triacantha. With this work, we describe two new species, Carlia insularis sp. nov and Carlia isostriacantha sp. nov. in the northwest of Australia. This contributes to increasing recognition that this region of tropical Australia has a rich and unique fauna.

Concepts: DNA, Species, Australia, Work in progress, A priori, A priori and a posteriori, Skink, Divergence


In 2014, the Joint United Nations Programme on HIV/AIDS released its 90-90-90 targets, which make laboratory diagnostics a cornerstone for measuring efforts toward the epidemic control of HIV. A data-driven laboratory harmonization and standardization approach is one way to create efficiencies and ensure optimal laboratory procurements. Following the 2008 “Maputo Declaration on Strengthening of Laboratory Systems”-a call for government leadership in harmonizing tiered laboratory networks and standardizing testing services-several national ministries of health requested that the United States Government and in-country partners help implement the recommendations by facilitating laboratory harmonization and standardization workshops, with a primary focus on improving HIV laboratory service delivery. Between 2007 and 2015, harmonization and standardization workshops were held in 8 African countries. This article reviews progress in the harmonization of laboratory systems in these 8 countries. We examined agreed-upon instrument lists established at the workshops and compared them against instrument data from laboratory quantification exercises over time. We used this measure as an indicator of adherence to national procurement policies. We found high levels of diversity across laboratories' diagnostic instruments, equipment, and services. This diversity contributes to different levels of compliance with expected service delivery standards. We believe the following challenges to be the most important to address: (1) lack of adherence to procurement policies, (2) absence or limited influence of a coordinating body to fully implement harmonization proposals, and (3) misalignment of laboratory policies with minimum packages of care and with national HIV care and treatment guidelines. Overall, the effort to implement the recommendations from the Maputo Declaration has had mixed success and is a work in progress. Program managers should continue efforts to advance the principles outlined in the Maputo Declaration. Quantification exercises are an important method of identifying instrument diversity, and provide an opportunity to measure efforts toward standardization.

Concepts: AIDS, Africa, Diagnosis, United States, Work in progress, Standardization, Standard, joint united nations programme on hiv/AIDS


Work in the development and evaluation of mindfulness-based interventions (MBIs) for cancer care has been underway for the last 20 years, and a growing body of literature now supports their efficacy. MBIs are particularly helpful in dealing with common experiences related to cancer diagnosis, treatment, and survivorship, including loss of control, uncertainty about the future, and fears of recurrence, as well as a range of physical and psychological symptoms, including depression, anxiety, insomnia, and fatigue. Our adaptation, mindfulness-based cancer recovery (MBCR), has resulted in improvements across a range of psychological and biological outcomes, including cortisol slopes, blood pressure, and telomere length, in various groups of cancer survivors. In this paper, I review the rationale for MBIs in cancer care and provide an overview of the state of the current literature, with a focus on results from three recent clinical trials conducted by our research group. These include a comparative efficacy trial comparing MBCR to supportive-expressive therapy in distressed breast cancer survivors, a non-inferiority trial comparing MBCR to cognitive behavioral therapy for insomnia in cancer survivors with clinical insomnia, and an online adaptation of MBCR for rural and remote cancer survivors without access to in-person groups. I conclude by outlining work in progress and future directions for MBI research and applications in cancer care.

Concepts: Anxiety, Psychology, Cancer, Breast cancer, Metastasis, Clinical psychology, Cognitive behavioral therapy, Work in progress