While this process of developmental OPC migration is well characterized, the nature of the molecular mediators that govern it remain largely unknown. Here, using zebrafish as a model, we demonstrate that Met signaling is required for initial developmental migration of OPCs, and, using cell-specific knock-down of Met signaling, show that Met acts cell-autonomously in OPCs. Taken together, these findings demonstrate  During vertebrate spinal cord development, oligodendrocyte progenitor cells (OPCs) are specified from ventral gliogenic precursors , the ligand for Met, acts as a mitogenic signal for OPCs  constructs, we show that Met acts cell-autonomously within OPCs. Together, our results demonstrate that Met signaling regulates initial OPC migration during developmental tiling.Here, we describe the identification of the Met receptor as an essential mediator of OPC migration. Using a combination of pharmacological and genetic manipulation with uva38met, fh534met, uva5Tg(sox10(4.9):tagrfp), Tg(olig2:vu12egfp) (vu234Tg(sox10(7.2):mrfp) :DNmet::IRES:egfp;cry:uva40egfp); Tg(olig1(5.3):DNmet::IRES:egfp;cry:uva39egfp); and fh528hgfa  from wildtype genomic DNA using the following primers: forward 5′-GTATGAAGCCTCTTGGCACAG-3′ and reverse 5′-CTGAAAAAAGATATTCAGAGAACATGG-3′, as previously described  and generated site-specific mutations in founders .fh555Tgmet enhancer trap line was generated using the CRISPR/Cas9-mediated knock-in strategy described in , 200 ng/μL Mbait gRNA, 20 ng/μL Mbait-hsp70-GFP plasmid, 800 ng/μL Cas9 protein (PNABio #CP02). Founders were screened for GFP expression replicating the known met expression pattern.The uva38met allele was created using CRISPR/Cas9 mutagenesis. Using CHOPCHOP, we generated a gRNA specific to exon 2 of the zebrafish met coding sequence with a target sequence of: AGTGCATTTACTCTGAGCGA , immersed in 0.8% low-melting point agarose and mounted in glass-bottomed 35 mm Petri dishes (Electron Microscopy Sciences). After mounting, the Petri dish was filled with egg water containing PTU and Tricaine. A 40× water objective (NA = 1.1) mounted on a motorized Zeis AxioObserver Z1 microscope equipped with a Quorum WaveFX-X1 (Quorum Technologies) or Andor CSU-W1 (Oxford Instruments) spinning disc confocal system was used to capture all images. Images were imported into MetaMorph (Molecular Devices) and/or ImageJ. Time-lapse images were analyzed using cell tracking software as previously described in , then permeabilized in acetone at RT for 5 min and at −20°C for 10 min, followed by a 5 min wash with PBSTx. Embryos were then blocked in 5% goat serum/PBSTx for 1 h, incubated in primary antibody with 5% goat serum/PBSTx for 1 h at RT and overnight at 4°C. Embryos were washed extensively with PBSTx at RT and incubated in secondary antibody overnight at 4°C. After antibody incubation, embryos were washed extensively with PBSTx and stored in PBS at 4°C until imaging. The following antibodies were used: rabbit anti-Sox10 (1:5000) (Dechorionated embryos and larvae were fixed with 4% PFA for 1 h at room temperature (RT), washed in PBSTX  for 5 min, followed by a 5 min wash with DWTx  . Kinase inhibitors used were 1 of 430 kinase inhibitors from the L1200 Kinase Inhibitor Library (Selleck Chem), MK-2461 (Selleck Chem), or Trichostatin-A (TSA) (Selleck Chem). Control siblings were treated with 1% DMSO in PTU egg water. The small molecule screen was conducted in triplicate.In our initial small molecule screen, dechorionated For the EdU incorporation assay, larvae were treated with 0.4 mM EdU in 4% DMSO from 70 to 74 hpf in PTU egg water at 28.5 °C then fixed for 1 h in 4% PFA at RT. Larvae were washed for 5 min with 1X PBSTX, 5 min in DWTX, then permeabilized with cold acetone for 10 min at −20°C and stained for EdU using the Click-it EdU Cell Proliferation kit for Imaging with Alexa Fluor 647 dye (ThermoFisher), as detailed in the kit protocol. Click-it reaction was performed for 1 h at RT and thoroughly washed overnight with PBSTX prior to imaging.uva38met are as follows: forward 5′-ATCGTACGCATGTGTTCTTCAG-3′ and reverse 5′-TGATGTCCGTGATGGAGATAAG-3′. The primers used for genotyping fh534met are as follows: forward 5′-AATCTCTGCCATGTTTTCCTGT-3′ and reverse 5′-AGTCCAAAACTATCCCAAGCAA-3′. The primers used for genotyping fh528hgfa are as follows: forward 5′-TGTAAAACGACGGCCAGTCTCCATGAAGACCTTAGTTGGC-3′ and reverse 5′-GTGTCTTGTGAACAGACCACACACACTGA-3′.Genomic DNA was extracted using HotSHOT (hot sodium hydroxide and tris) and PCR was performed using GoTaq green master mix (Promega) , with 1% DMSO as a control, 0.2 μM TSA in 1% DMSO as a control, or 10 μM of 1 of 430 kinase inhibitors from the Selleck Kinase Inhibitor Library in 1% DMSO. We used TSA as a positive control because it is a histone deacetylase inhibitor that blocks OPC specification and therefore, embryos treated with this compound would show significantly reduced OPC migration into the dorsal spinal cord   .We next wanted to determine if treatment with MK2461 altered other aspects of OPC migration, including velocity and distance traveled. To do this, we used our cell-tracking software to analyze our time-lapse movies, like those shown in in vitro studies of mouse and rat OPCs used antibody labeling to show that OPCs express the Met receptor   . By 55 here met+ . The conto 8.56% . These folig2:egfp zebrafish larvae with a 1% DMSO control or increasing doses of MK2461 in 1% DMSO and quantified the number of +olig2 OLCs in the dorsal spinal cord at 76 hpf. We found that increasing doses of MK2461 resulted in decreasing numbers of OLCs in the dorsal spinal cord compared to DMSO-treated larvae (P < 0.0001)  (P = 0.0349) (P < 0.0001)  . To more0+ cells . These s0+ cells , and the 0.0001) . Interes 0.0349) . Additio 0.0001) . We belimet that results in an early stop codon . Finally, to confirm our met allele contained a deleterious mutation in met, we crossed a heterozygous uva38met adult with a fh534met heterozygous adult, which has a 25 base pair deletion which leads to a premature stop at amino acid 1105, and imaged the spinal cord of 72 hpf olig2:egfp mutant larvae . In these trans-heterozygous uva38/fh534met larvae, we observed a significant decrease in the number of dorsal OLCs when compared with wildtype siblings .Given the migration phenotype we observed with the c-Met inhibitor, MK2461, and the expression pattern of Met in zebrafish OLCs, we sought to further investigate Met as a mediator of OPC migration during development using CRISPR/Cas9 mutagenesis that resulted in a 16 base pair insertion in the second exon of op codon . This muop codon . Importauva38met allele to assess the role of met in regulating developmental OPC migration. Using in vivo, time-lapse imaging in combination with our cell-tracking software in 55 hpf olig2:egfp;+/+met, +/uva38met, and uva38/uva38met larvae, we analyzed OPC migration    . Taken together, our results demonstrate that met is required for dorsal OPC migration during developmental OPC tiling.We next used this new  0.0307) . Interes 0.0207) . There w 0.0079)  (Zhang a 0.0079) . In contory OPCs . Finallymet mutation on developmental OPC migration, we performed serial sectioning on 76 hpf olig2:egfp;sox10:mrfp;+/+met, +/uva38met, and uva38/uva38met larvae. We then imaged transverse sections of the spinal cord and assessed the location and number of OLCs (uva38/uva38met larvae compared to wildtype siblings (P = 0.0137)   . The increased number of OPCs in the pMN domain in uva38/uva38met larvae compared to wildtype siblings, and the OPC process extension behavior in our time-lapse imaging indicate that there is a reduction in the number of OPCs that are migrating out of the pMN domain. This data supports our hypothesis that OPCs require met for initial migration out of the pMN domain during development, while sparing OPC specification.To more closely examine the effect of a  of OLCs . Similar 0.0137) . Additio 0.0014) . This fi 0.0013) . This dahgfa mutants as well . We hypothesized that we would see a similar change in OPC migration to what we observed in met mutant larvae. Excitingly, we observed a decrease in the overall number of OLCs in fh528/fh528hgfa larvae compared to wildtype siblings (P = 0.0008) . Furthermore, we found that there was a significant decrease in the number of dorsal OPCs in fh528/fh528hgfa larvae compared to wildtype siblings (P < 0.0001), though the number of ventral OLCs was not significantly different compared to wildtype siblings . Finally, we saw an increase in the number of OLCs in the pMN domain in fh528/fh528hgfa larvae compared to wildtype siblings (P = 0.0004) . These data are all consistent with what we observed in our met mutant larvae and further support that Met signaling is required for developmental OPC migration.Because Hgf is the ligand for the Met receptor, we wanted to investigate whether there would also be a reduction in dorsal OLC numbers in uva38/uva38met larvae could be caused by either a reduction in OPC specification, which would lead to fewer OLCs in the spinal cord, or a reduction in OPC proliferation, which would result in wildtype numbers of OPCs during specification, but fewer OPCs during the migratory period. Met has been implicated in regulating cellular proliferation in a number of different cell types including hepatocytes, melanocytes, and other epithelial cell types . We chose 48 hpf because it is sufficiently after the window of OPC specification which begins at 36 hpf, but prior to the main migratory period of OPCs which begins at approximately 55 hpf .From these data, we hypothesize that the reduction in the number of OLCs in uva38/uva38met larvae, we next hypothesized that the reduction in the number of OLCs in uva38/uva38met larvae was caused by a decrease in OPC proliferation, which has previously been demonstrated  from 70 to 74 hpf in order to detect DNA synthesis in proliferative cells  (uva38/uva38met larvae is due to a decrease in proliferation of OLCs and that met plays a role in regulating OLC proliferation and migration during development.With OPC specification being unaffected in ve cells . We thendU+ OLCs . We obse 0.0249) . These rmet mutant studies were not due to non-cell autonomous effects on OPCs. Therefore, we created cell lineage specific, Met dominant negative constructs to specifically perturb met signaling in OLCs.During development, Met is expressed in a number of developing central nervous system (CNS) neural populations, including motor neurons . Becausein vitro cell culture and zebrafish larvae for cell-specific reduction of Met signaling  (olig1:DNmet larvae (sox10:DNmet larvae exhibited a significant increase in the number of OPCs in the pMN domain compared to both wildtype (P = 0.0063) and olig1:DNmet larvae at 55 hpf (P < 0.0001)  and olig1:DNmet larvae (P < 0.0001)  . In contt larvae , the sox 0.0001) . These r 0.0001) . These rsox10:DNmet and olig1:DNmet zebrafish larvae (sox10:DNmet larvae compared to both wildtype (P = 0.0042) and olig1:DNmet (P = 0.0461) larvae (sox10:DNmet larvae compared to wildtype (P = 0.0286) (sox10:DNmet was significantly increased compared to both wildtype (P < 0.0001) and olig1:DNmet (P < 0.0001) larvae , indicating that reducing Met signaling later in development can also affect OLC positioning (P = 0.0147)  larvae . Additio 0.0286) . Concord) larvae . Furtheris stage . Additio 0.0147) . Taken tOPCs are a group of highly motile and dynamic cells that are specified during early development. Following specification, they migrate rapidly to become evenly distributed throughout the CNS in a process termed tiling. While this process is described phenomenologically in the literature, there is still much left to be discovered about how tiling is molecularly regulated (in vivo investigation demonstrating that loss of Met signaling reduces OPC migration. Previous in vitro studies demonstrated that applying Hgf to primary OPC cultures induced chemotaxis and proliferation (in vitro data combined with our in vivo work demonstrates that Met expression on OPCs regulates their migration.This work represents a significant advance in the understanding of Met signaling in OPC development because it is the first feration . This in+/uva38met larvae where they occasionally exhibited OLC migration phenotypes similar to met mutants. A handful of studies have demonstrated that heterozygous met mutations can result in pathologically relevant outcomes (met mutants do not achieve this level of Met signaling resulting in the observed intermediate phenotypes.Interestingly, in our studies, we observed a trend in What still remains unclear regarding the Met signaling pathway and OPC migration, is the source of Hgf. Some studies suggest that chemotropic factors released by astrocytes are influential in regulating OPC migration and positioning in the spinal cord (met mutants can live into adulthood and therefore, can be utilized to study these tiling processes in mature animals (Beyond developmental tiling, OPCs remain evenly tiled throughout life and utilize similar processes of migration, proliferation, contact-mediated repulsion, and apoptosis to maintain their spacing ( animals . Additiohttps://doi.org/10.25387/g3.14988414.Fish lines and plasmids are available upon request. The authors affirm that all data necessary for confirming the conclusions of the article are present within the article, figures, and table. Supplemental Material available at figshare:


Antibodies of the IgG4 isotype are strongly associated with allergic disease but have several properties such as not precipitating with allergens, not activating complement and poor binding to Fcγ receptors that argue against a pro-inflammatory role. In keeping with that, IgG4 antibodies are a striking feature of the response to immunotherapy. In two naturally occurring situations IgG4 antibodies are common with low or absent IgE antibodies. The first example is children raised in a house with a cat and the second is eosinophilic esophagitis (EoE). In many population-based cohorts, the ownership of a cat in early childhood is associated with a decreased prevalence of a cat allergy at age 10. The second example  is a novel form of food allergy that is not mediated by IgE and is related to consuming cow’s milk or wheat. In EoE, patients have IgG4 to milk proteins in high > 10 µg/mL or very high > 100 µg/mL titers. Enigmatically these patients are found to have deposits of IgG4 in the wall of their inflamed esophagus. The factors that have given rise to EoE remain unclear; however, changes in food processing over the past 50 years, particularly ultra-heat treatment and the high pressure homogenization of milk, represent a logical hypothesis. The IgG4 isotype was first described together with the other two minor sub-classes i.e., IgG2, IgG3) that make up IgG prior to 1970 , IgG3 th. FinallyThe reputation that IgG4 antibodies could be anti-inflammatory or tolerogenic was enhanced by studies showing increases in a specific IgG4 in response to immunotherapy with pollen or mite extracts ,8. In adTwenty years ago, Aalberse and his colleagues in Amsterdam presented evidence that some of the circulating allergen-specific IgG4 molecules were bispecific . He pursThe measurement of specific IgG4 antibodies to allergens did not become possible for use in clinical investigation until the development of monoclonal antibodies (mAb) to this isotype. The first mAb available in Europe was produced by Jefferis in Birmingham, UK . Those aToday there is a large number of publications reporting results for specific IgG4 with either microchip techniques or the modified protocol with ImmunoCAP ,16. The Much of the evidence about the clinical relevance of IgG4 antibodies has come from studies on immunotherapy for pollen, venom or inhaled allergens other than pollen. In those studies, it was clear that titers of specific IgG4 rise significantly and may reach levels at which they can inhibit in vitro tests such as the basophil activation test (BAT).There have also been studies on IgG4 development in birth cohorts using the Immuno Solid-phase Allergen Chip (ISAC). The results there have shown a wide range but consistently there have been high results for IgG4 to the milk proteins compared with the pollens . HoweverAlthough cats are undoubtedly an excellent source of airborne allergens and fully capable of making children sick with asthma, there is a persisting enigma about the relationship between cat ownership and allergic reactions to cat allergens. When Hesselmar and Bjorksten in Sweden first reported that cat ownership could reduce the risk of a cat allergy, there was, as is normal in science, widespread disbelief . HoweverThere are several factors that are relevant to understanding how or why sensitization to cat allergens could be more common among children living in homes without a cat. Firstly, cats produce large quantities of allergens that remain airborne in such a way that daily exposure is at least ten-fold greater than that to other inhalant allergens. Secondly, the direct measurement of Fel d 1 in dust samples has demonstrated significant quantities of this allergen in public places and schools as well as in homes without a cat ,32. ThosStudies in different environments or with different protocols have given mixed results on the effects of cat ownership. However, it is clear that the effect of cat ownership on the rest of the community depends on the prevalence of cat ownership in the community. If cats are present in less than 10% of homes, then cat ownership is likely to be a significant risk factor for sensitization . In compOver the 35 years that Peter Heymann has been in charge of the pediatric allergy clinic at the University of Virginia, three different forms of food allergy have increased. In two cases, they have become apparent for the first time. These increases between 1990 and the present should be compared with the history of seasonal allergic rhinitis, which increased steadily from 1870 to its peak around 1970 while asthma in childhood increased dramatically from 1960 to around 2000 . The thrIn 2014, Dr. Clayton working with Kathy Peterson in the adult gastroenterology group in University of Utah School of Medicine in Salt Lake City reported striking evidence that adult patients with EoE have elevated serum food-specific IgG4 antibodies . In addiThe association of tissue deposits of IgG4 and elevated total serum IgG4 has been seen before in the so called “IgG4-related diseases”. However, in those diseases, the specificity of IgG4 antibodies is generally not known. The titers of specific IgG4 to milk and wheat proteins in children with EoE are the highest values for IgG4 to any antigen that we are aware of. Indeed, a few sera from patients with EoE have collective quantities of specific IgG4 as high as 40% of total IgG4 . We woulThe presence of high titers of specific IgG4 to Bos d 4, Bos d 5 and/or Bos d 8 in patients who have extracellular deposits of IgG4 in the esophagus raises several questions. The primary questions should be why do these patients make such striking antibody responses to these important food sources and is there a reason why this has increased? The secondary question is why does IgG4 accumulate in the local tissue? Antibodies of this isotype have a molecular weight of ~180,000 and should rapidly diffuse out of local tissue or away from a plasma cell unless they are bound in some way. However, as we discussed earlier, IgG4 antibodies in general do not form complexes or bind to most Fc receptors. Preliminary data suggest that milk and or wheat proteins can also accumulate in the areas of the esophagus where deposits of IgG4 are present.(1)It has been suggested that antibodies of this isotype have a tendency to aggregate if present in high concentrations .(2)Bivalent IgG4 antibodies coming out of a plasma cell could form complexes if they encounter milk proteins or other relevant antigens close to their site of production. A few of the bispecific molecules of IgG4 could be of the A1 + A2 type See B potenti(3)While most of the protein in the whey fraction of milk is present as single molecules, the same is not true of casein molecules, which form micelles that can reach large sizes. It is this characteristic of caseins that leads them to form “curds” and thus in most cheeses they are the major component. The molecules of casein also adhere strongly to the disrupted smaller fat particles in homogenized milk  Figure . If multThe accumulation of IgG4 molecules locally in the esophagus could theoretically occur as a result of several processes:It is important to recognize that milk protein consumption is measured in grams per day. This is thousands of times greater than any inhalant allergen. It has been reported by several groups that treatment with oral immunotherapy (OIT) in patients with immediate reactions to peanuts, milk or egg can give rise to an EoE-like condition . There aWhen the senior author of this manuscript was a student at St. Thomas’s Hospital in the 1960s, Norman Barrett was still carrying out ward rounds. At that time, he apparently was not and certainly we students were not aware of an eosinophilic inflammatory disease of the esophagus that could give rise to severe symptoms or obstruction. In keeping with that, neither PWH nor TP-M were aware of cases of EoE in the clinics or emergency departments of the University of Virginia in the 1980s. Thus, the real question is what has happened that could lead to the emergence of this disease in the 1990s and the increase since then? One obvious possibility is that changes in the processing of food lead to forms of milk and/or wheat that are more immunogenic. Two aspects of the processing of milk could be relevant; they are ultra-heat treatment and homogenization. Until recently, bottled milk delivered to the door in London had been pasteurized at 75 °C and was not homogenized. By contrast, greater than 90% of cow’s milk sold in the USA today has been heated to 135–140 °C as well as being homogenized. In fact, there is no such thing as non-homogenized ultra-heat-treated milk because the fat in non-homogenized milk accumulates at the surface as cream but over time the cream layer changes to a form more like brittle rubber. The homogenization of milk started as early as the 1940s and has not only become more common but has also become more efficient. The details of this process of “high-pressure” may well be relevant to understanding the increases in EoE ,55. We hThe primary objective of homogenization is to decrease the size of the fat droplets so that the milk becomes a stable emulsion. The average change in the diameter of these droplets is from 3 microns to 300 nanometers. This change results in a thousand-fold increase in the number of fat droplets and a tenfold increase in the total surface area. The change in the surface area leads to a profound disruption of the surface of the droplets, which in turn encourages the adherence of milk proteins to the surface of the particles . The strThree forms of food allergy have dramatically changed the clinical practice of allergic disease in the United States. In addition, they have provided exceptional opportunities for research into both the mechanisms of the disease and the epidemiology of changes in the prevalence. Although two of the syndromes are characterized by anaphylaxis, which can become severe, the timing in relation to eating is completely different. The speed with which allergic children can react to peanut exposure is well-known. In the alpha-gal syndrome (AGS), although reactions are generally delayed for at least 2 h, once started they can become severe rapidly . FinallyBox 1.IgEIgG4 to IgE RatioIncrease: decrease in the skin barrier possibly related to detergents; a strong correlation with atopic dermatitis.I. Peanut anaphylaxis: rapid allergic reactions occurring with peanuts or other foods. High titer IgE to defined proteins from the relevant foods.High~1:1Increase: food processing and damage to the esophageal barrier.II. Eosinophilic esophagitis (EoE): delayed onset of symptoms ; low IgE and high or very high IgG4 to cow’s milk and/or wheat proteins.Low or negative~500:1Increase: increased bites from Lone Star ticks; in the USA, associated with an extraordinary increase in the deer population close to houses.III. Delayed anaphylaxis to mammalian meat: alpha-gal syndrome (AGS) reactions delayed in onset but can be severe.Low to high~1:1Studying IgG4 antibody responses, the differences between common inhalants such as pollen or dust mite when compared with cat allergens can best be explained by the quantity of exposure. For most inhalant allergens, exposure is measured in ng/day; indeed, Marsh estimated that exposure to specific pollen allergens was ~1 µg/year . In keepAmblyomma americanum. Tick bites can give rise to high levels of IgE specific for the oligosaccharide galactose alpha-1,3-galactose . The production of antibodies to this oligosaccharide can occur because the gene for the relevant alpha-1,3-galactosyltransferase became inactivated in primates around 20 million years ago [In the United States, the increase in AGS is almost certainly related to an increased exposure to the Lone Star tick ears ago ,63. Althears ago ,43. InteWe have described two situations where the increased levels of specific IgG4 to an allergen are associated with a difference in an allergic disease. Firstly, many children living in a house with a cat produce relatively large quantities of specific IgG4 to cat allergens together with low levels of specific IgE. This form of response is not related to asthma and can lead to a situation where owning a cat decreases your child’s risk of having asthma related to cat allergens ,28,33,36


Overuse of antibiotics is a major challenge and undermines measures to control drug resistance worldwide. Postnatal women and newborns are at risk of infections and are often prescribed prophylactic antibiotics although there is no evidence to support their universal use in either group.We performed point prevalence surveys in three hospitals in Dar es Salaam, Tanzania, in 2018 to collect descriptive data on antibiotic use and infections, in maternity and neonatal wards.Prescribing of antibiotics was high in all three hospitals ranging from 90% (43/48) to 100% (34/34) in women after cesarean section, from 1.4% (1/73) to 63% (30/48) in women after vaginal delivery, and from 89% (76/85) to 100% (77/77) in neonates. The most common reason for prescribing antibiotics was medical prophylaxis in both maternity and neonatal wards.We observed substantial overuse of antibiotics in postnatal women and newborns. This calls for urgent antibiotic stewardship programs in Tanzanian hospitals to curb this inappropriate use and limit the spread of antimicrobial resistance. Overuse of antibiotics is a major challenge worldwide and undermines measures to control antimicrobial resistance (AMR). Failure to control AMR is leading to an increase in mortality, prolonged hospital stays, worsening of clinical conditions and increase in the cost for treatments –3. AMR aThere are multiple reports of high levels of unnecessary prescriptions of antibiotics for both postnatal women, following either cesarean section (CS) or vaginal delivery, and neonates –13. In SSimilarly, in Tanzania there are few formal studies of prescribing practices for antibiotics during the postpartum and neonatal period, where maternal and neonatal sepsis are estimated to be responsible for 13% and 20% mortality respectively , 16. As We conducted point prevalence surveys (PPS) of healthcare-associated infection (HAI) and antibiotic use in maternity, gynecological and neonatal wards as part of the CLEAN study July 2018–May 2019), a pilot evaluation of an environmental hygiene training intervention . The rou–May 2019Two doctors from each hospital’s Obstetric Department were trained in how to collect PPS data. They conducted the survey on one weekday per month for three consecutive months, with direct supervision from one investigator (AMK). Data were collected on structured questionnaires adapted from the European Centre for Disease Prevention and Control (ECDC) PPS protocol .This tooData entry and initial cleaning was done in the HelicsWin.NeT version no 2.4, the recommended software for the analysis of the PPS in the ECDC protocol. Further cleaning and data analysis were conducted in Stata version 14.1. For each ward, the prevalence of antibiotic use was calculated as the percentage of total patients on antibiotics admitted in the ward at the time of the survey.We collected data from a total of 376 mothers and 162 newborns across three rounds of the PPS in each hospital. Hospital 1 had a total of 173 mothers and 77 newborns, hospital 2 had 258 mothers and 85 newborns, while hospital 3 had 107 mothers only.The use of antibiotics in CS wards was extremely high: 90% (43/48) of patients in Hospital 1, 96% (45/47) in Hospital 2 and 100% (34/34) in Hospital 3. In Hospital 1, all mothers with suspected infections were transferred to the gynecology ward, thus all the antibiotics prescribed in CS ward were for post-operative surgical prophylaxis. At Hospital 2, only four out of 45 mothers on antibiotic treatment were reported to have active infection; one with deep surgical site infection (SSI) (first survey) and three with superficial SSI (third survey). All other women  were receiving antibiotics for post-operative surgical prophylaxis. In Hospital 3, all admitted mothers  were on antibiotics. One SSI was reported in the first survey, but all other antibiotics were prescribed for surgical prophylaxis (see Table All newborns (77/77) in Hospital 1 were receiving antibiotics; 17% 13/77) had HAI, 1.3% (1/77) had community-acquired infection, and the rest  were being given antibiotics for medical prophylaxis. In Hospital 2, 89% (76/85) were receiving antibiotics across all three rounds of the survey, increasing from 80% (24/30) during the first round to 100% (28/28) in the third round. Out of 76 newborns on antibiotics, 4% (3/76) had community-acquired infections, 40% (30/76) had HAI and 57% (43/76) had no clear indication for antibiotic use (see Table /77 had HWe performed repeated rounds of PPS for antibiotic use in the maternity and neonatal departments of three busy public sector hospitals in urban Tanzania. We found high levels of antibiotic use in women following vaginal delivery or caesarean section. Around 95% of surveyed women who had CS were receiving antibiotics, and among these, 95% were receiving them for post-operative surgical prophylaxis lasting more than one day. The high use was observed in all three hospitals and in all surveys. Prescription of antibiotics in post-natal wards varied widely between hospitals: while Hospital 1 prescribed antibiotics in about 60% of women, Hospitals 2 and 3 only prescribed 11% and 1.4% respectively. The most common reasons for antibiotic prescription were medical or surgical prophylaxis in all hospitals. Similarly, we observed high use of antibiotics, at around 90%, in neonatal wards, with the vast majority being used for medical prophylaxis or without a clear indication. This near-universal prescription of antibiotics after CS is a common clinical practice in low income countries –23, despIn this study, we expected to see a difference in antibiotic use between the CS and vaginal delivery because CS carries higher risk of infection. Prophylactic antibiotics are recommended in CS but they should be given pre-rather than post-operatively. Irrational overuse of antibiotics is likely to ultimately lead to severe illness and death in mothers and newborns as a result of increasing levels of antibiotic resistance in low-income countries . More thThe findings in this study might have been subjected to a form of Hawthorne effect since the clinicians involved in the data collection were also working on the maternity wards and prescribing antibiotics to postnatal women. It is therefore possible that performing the survey increased their concern about infections and could have influenced their prescribing practice in later rounds of the survey. This may partly explain the increase in prescribing seen at Hospital 1 during the course of the study.There was an extremely high prevalence of antibiotic prescribing for prophylaxis in maternal and neonatal units in hospitals in Dar es Salaam, Tanzania. Better infection control policies, local and national guidelines, and antimicrobial stewardship programs need to be implemented to avoid unnecessary prescription of the antibiotics and promotion of antibiotic resistance.


We present a European Union/European Economic Area-wide overview of the changes in consumption of antibacterials for systemic use (ATC J01) in the community between 2019 and 2020 as reported to the European Surveillance of Antimicrobial Consumption Network. Overall antibiotic consumption decreased by 18.3% between 2019 and 2020, the largest annual decrease in the network's two-decade history. We observed a strong association between the level of community antibiotic consumption in 2019 and the size of the decrease between 2019 and 2020.  The ongoing coronavirus disease COVID-19) pandemic has since its start in early 2020 affected societies worldwide. In addition to the direct COVID-19-related morbidity and mortality, secondary effects on general communicable disease epidemiology and healthcare system delivery have also been reported [9 pandemiHere, we present a European Union (EU)/European Economic Area (EEA)-wide overview of the changes in antibiotic consumption in the community in 2020 compared with previous years. We analysed the consumption of antibacterials for systemic use (ATC group J01), and focused on the community, i.e. the primary care sector, as this is where the changes between 2019 and 2020 were the largest at EU/EEA level and the most consistent among EU/EEA countries . Our analyses are based on data reported to the European Surveillance of Antimicrobial Consumption Network (ESAC-Net), collected using a methodology described elsewhere  and exprFor individual groups of antibiotics, the largest decrease in terms of DDD/1,000 inhabitants/day between 2019 and 2020 was observed for penicillins , followed by other beta-lactam antibacterials , macrolides, lincosamides and streptogramins , quinolones , tetracyclines , sulfonamides and trimethoprim , other antibacterials , and ATC groups J01B, J01G and J01R combined ; −0.01 DDD/1,000 inhabitants/day; −9.3%) .Twenty-seven countries reported separate data on community consumption for 2019 and 2020. Of these, 26 reported a decrease in community consumption of antibacterials for systemic use in 2020 compared with 2019, while one country (Bulgaria) reported an increase during the same period .Among the 26 countries reporting a decrease, there was a positive association between the level of antibiotic consumption in 2019 and the size of the decrease in antibiotic consumption between 2019 and 2020 measured in DDD/1,000 inhabitants/day ; the decrease was proportionally larger in countries with high community antibiotic consumption than in countries with low antibiotic consumption .For individual groups of antibiotics, there were various patterns of change in the 26 countries that reported a decrease overall. All 26 countries reported a decrease in the consumption of penicillins (ATC J01C) between 2019 and 2020, which corresponded to the largest reduction when expressed in DDD/1,000 inhabitants/day. A majority of countries also reported large reductions in the consumption of other beta-lactams, which includes cephalosporins (J01D), and of macrolides, lincosamides and streptogramins (J01F) . Only twThe unprecedented decrease in community antibiotic consumption noted in the EU/EEA between 2019 and 2020 is the largest in ESAC-Net’s two-decade long antimicrobial consumption surveillance history, and one example of the far-reaching consequences of the COVID-19 pandemic. Although similar changes in community antibiotic consumption have been described at the local and national levels -10, thisBecause patient-level data are lacking in ESAC-Net, we could not assess whether the observed decrease reflects concomitant changes in disease transmission, healthcare utilisation patterns or prescription practices. Nevertheless, the large decrease noted for antibiotics commonly used to treat respiratory tract infections, e.g. penicillins and other beta-lactam antibacterials, is in line with the reported low incidence of non-COVID-19-related respiratory tract infections in the EU/EEA in 2020 . This haInversely, two countries with high community antibiotic consumption reported either an increase (Bulgaria) or a comparatively small decrease (Romania) between 2019 and 2020. This was mainly explained by a large increase in the community consumption of macrolides, and specifically azithromycin. Azithromycin has been postulated to have antiviral and anti-inflammatory activity and has been studied for the treatment of COVID-19, however, multiple studies did not identify any clinical benefit .It cannot be excluded that the ongoing COVID-19 pandemic could have impacted the quality of the data. However, with the exception of Luxembourg that implemented a change in data processing in 2020, we are not aware of any other changes in data sources or data collection processes between 2019 and 2020. Evidence-based international guidelines have discouraged antibiotics for prophylaxis or treatment in patients with mild or moderate COVID-19 infection without a suspicion of a bacterial co-infection ,16, whicThe large changes in antibiotic consumption concomitant with the COVID-19 pandemic need to be further evaluated, both in countries with high and low antibiotic consumption, and areas of inappropriate antibiotic use need to be addressed within antimicrobial stewardship programmes in outpatient settings. It is still unclear whether this reduced community antibiotic consumption was sustained throughout 2021 and what implications it may have on antibiotic resistance. Robust surveillance systems will continue to be vital to monitor the situation.


Nitrofurantoin is an antimicrobial agent obtained through the addition of a nitro group and a side chain containing hydantoin to a furan ring. The interactions of the antibiotic with human serum albumin (HSA) have been investigated by fluorescence, UV-VIS, Fourier transform infrared spectroscopy (FTIR) spectroscopy, and protein-ligand docking studies. The fluorescence studies indicate that the binding site of the additive involves modifications of the environment around Trp214 at the level of subdomain IIA. Fluorescence and UV-VIS spectroscopy, displacement studies, and FTIR experiments show the association mode of nitrofurantoin to HSA, suggesting that the primary binding site of the antibiotic is located in Sudlow’s site I. Molecular modeling suggests that nitrofurantoin is involved in the formation of hydrogen bonds with Trp214, Arg218, and Ser454, and is located in the hydrophobic cavity of subdomain IIA. Moreover, the curve-fitting results of the infrared Amide I’ band indicate that the binding of nitrofurantoin induces little change in the protein secondary structure. Overall, these data clarify the blood transportation process of nitrofurantoin and its rapid transfer to the kidney for its elimination, hence leading to a better understanding of its biological effects and being able to design other molecules, based on nitrofurantoin, with a higher biological potential. E. coli and Citrobacter spp. are sensitive  is the concentration of the quencher. The 0/F versus [Q] at different temperatures. The KSV values obtained at 293, 298, 304, 310, and 315 K are 2.48 (±0.32) × 104, 2.63 (±0.22) × 104, 2.7 (±0.18) × 104, 2.86 (±0.30) × 104, and 2.98 (±0.27) × 104 M−1, respectively. Nitrofurantoin is soluble in a buffer solution and this may accelerate its diffusion rate and hence its collision with fluorophore.Therefore, the area surrounding the tryptophan residue is highly hydrophobic. Following this, the well-known Stern-Volmer equation was employed to define the mechanism of fluorescence quenching of nitrofurantoin:a is the modified Stern−Volmer association constant for the accessible fluorophores, and fa is the fraction of accessible fluorescence. The linear regression analysis of F0/(F0-F) versus 1/[Q] is shown in a values are 2.55 × 104, 2.48 × 104, 2.28 × 104, 2.19 × 104, and 2.15 × 104 L mol−1 at 293, 298, 304, 310, and 315 K, respectively. This shows that the binding constant is moderate and the effect of temperature is not significant. The analysis of the plots showed that, at the tested concentrations, there is a good linear relationship, indicating that the quenching mechanism is driven by the formation of a complex.The fluorescence data were further examined using the modified Stern−Volmer equation:n is the number of binding sites per HSA. In 0-F)/F as a function of log[Q] at 310 K is shown. The values of n are approximately equal to 1, which demonstrates that there is a single class-binding site for nitrofurantoin in the proximity of the tryptophan residue.The binding ability of a compound to HSA is very useful for evaluating its biological and, eventual, therapeutic potential, because it can also influence its stability and toxicity, as well as the rapidity of the renal excretion. The independent bind of small molecules to a set of equivalent sites on a macromolecule can be described by analyzing the equilibrium between free and bound molecules using the following equation:4 L/mol) [4 L/mol, highlighting that the binding between nitrofurantoin and HSA is moderate in strength, and the formation of the complex is reversible. In this way, the antibiotic can be stored and carried around the body by HSA. The moderate value of K indicates that the drug does not remain so much time linked to HSA because other molecules with higher affinity compete with nitrofurantoin for the binding, and this decreases its availability in the circulating system and probably is responsible also of its rapid elimination.The binding strength of a compound to HSA is one of the main elements in its availability to diffuse in the organism and, through the circulation system, to reach its target organ or to be eliminated by the organism . The bin4 L/mol) . The binThe binding of molecules to macromolecules involves mainly non-covalent interactions . These types of forces can be analyzed by determining the thermodynamic parameters of the binding reaction ,33,34,35off plot D, while The van’t Hoff plot for the evaluation of the thermodynamic parameters due to the nitrofurantoin-HSA interaction is depicted in The positive ΔS value is evidence for the formation of hydrophobic interactions, while the negative value of ΔH suggests that the binding process is predominately enthalpy driven and is probably due to hydrogen binding interactions. The negative ΔG values, accompanied by positive entropy change (ΔS), are indicative of a spontaneous process during the binding of nitrofurantoin to HSA. Moreover, the free energy change in the binding is a direct consequence of the strength of the interaction (such as protein molecules). Therefore, both hydrophobic interactions and hydrogen bonds play a major role in the binding of an antibiotic agent to HSA according to above mentioned data.Warfarin, ibuprofen, and digitoxin, namely markers of HSA binding sites I, II, and III, respectively, were employed to carry out displacement binding experiments and to gather further information on the nitrofurantoin binding site. The fluorescence emission spectra of nitrofurantoin-HSA complex spectra were recorded both in the absence and presence of increasing concentrations of warfarin, ibuprofen, and digitoxin. As displayed in −1, corresponding mainly to the α-helix. In addition, the interaction between nitrofurantoin and HSA brought about a change, as well as a slight shift in band intensity, at both 1652 cm−1 and 1680 cm−1 of the FTIR spectra, thus suggesting a rapid variation in the association and dissociation of nitrofurantoin. This was further reinforced by the observed increase of absorbance values of both amide II’ and amide II bands.In order to investigate the modification of the HSA secondary structure after binding to nitrofurantoin, as well as its mechanisms of interaction to the protein, we exploited FTIR spectroscopy ,39,40,41The absorption of these two bands arises from the amide bonds that link the amino acids. The absorption is primarily due to bending vibrations of the N−H bond and, because they are involved in hydrogen bonding occurring among the different elements of a secondary structure (as well as in H–D exchange), they are sensitive to the changes in secondary structure and to the interaction with the surrounding environment of the protein.Our computational modeling study was performed on a crystal structure of HSA taken from the Protein Data Bank (entry PDB code 1GNI) in order to identify the possible binding site of nitrofurantoin. Based on the displace experimental results and to further define the binding site, the molecule docking simulation box was set on Sudlow’s site I. The best energy ranked result −5.43 kcal/mol) showed that nitrofurantoin may be situated within subdomain IIA, formed by six helices, which is consistent with the supposition on the basis of our experimental results. The nitro group and the oxygen of the furan ring established a hydrogen bond with Trp214 and Arg218, respectively, and the C=N−N unit of hydantoin established a further one with Ser454 . The nit kcal/molSV in the Stern-Volmer dynamic quenching equation and the evaluation of the other thermodynamic and kinetic parameters indicate that there is the formation of a binary complex in a single site in the neighboring of a tryptophan residue. Both hydrophobic interactions and hydrogen bonds are acknowledged to have a crucial role in the binding of nitrofurantoin to HSA, as in the case of other antibiotics [The identification and characterization of novel antibiotics for clinical utilization is one of the greatest challenges of current basic experimentation. Indeed, discoveries in this field have always represented a remarkable achievement in the history of medicine. Moreover, the development and diffusion of bacterial antibiotic-resistance, due to the modification of different proteins and hence cellular processes , is a major public health issue. Therefore, researchers are continuously trying to develop new agents of both a natural and synthetic origin that are able to overcome this resistance and fight the major issue bacterial infections still represent ,46,47. Tibiotics . The binBoth HSA and nitrofurantoin were purchased from MERCH . We employed no fat-free HSA so as to resemble a much closer situation closer to what occurs in vivo. Double distilled water was employed to prepare all of the solutions.UV-VIS spectroscopy was employed to study the interaction between HSA and nitrofurantoin, adding increasing amounts of the former (up to 90 µM) to 60 µM of the latter in a 20 mM phosphate buffer with pH 7.4. The absorption spectra were recorded from 220 to 480 nm through a spectrophotometer with a quartz cuvette. The spectra of each buffer solution were subtracted from the sample ones.2O at 298 K for 1 day and was lyophilized again. This procedure was carried out twice for each sample. The FTIR spectra (1350 cm−1and 1750 cm−1) were measured through a Bruker Vertex 80 spectrometer under a vacuum, after dissolving the samples in 20 mM phosphate buffer with pH 7.4 in D2O. The pD value of the HSA solution was measured and corrected according to pD = pH + 0.4 for deuterium isotope effects. A pair of CaF2 windows divided by a 25 μm Teflon spacers were employed to place the protein solution (30 mg/mL), with or without nitrofurantoin or warfarin. Sixty-four interferograms with a spectral resolution of 4 cm−1 were collected for each sample. The IR spectra of the buffer with or without nitrofurantoin or warfarin were subtracted from the spectra of the corresponding sample.Lyophilized HSA was dissolved in DThe HSA spectra with or without nitrofurantoin or warfarin were smoothed by employing the Loess algorithm, and the deconvolved spectra were fitted with Gaussian band profiles. From these spectra, the initial values for the peak heights and widths were assessed. For the final fits, the positions, heights, and widths of each band were varied simultaneously. The curve fitting process was calculated through Seasolve PeakFit v4.12 software.−5 mol/L HSA in 20 mM sodium phosphate buffer (pH 7.4) was titrated by a successive additions of nitrofurantoin stock solution (1.0 × 10−3 mol/L) to give a final concentration ranging from 0 to 3.0 × 10−5 mol/L. The fluorescence spectra were recorded at 293, 298, 304, 310, and 315 K in the wavelength range of 300−400 nm with an excitation wavelength at 280 nm.The fluorescence spectra were recorded using a FluoroMax-4 spectrofluorometer by Horiba Jobin-Yvon, equipped with a pulsed xenon lamp and an F-3006 Autotitration Injector with two Hamilton Syringes . The resolutions of the wavelength selectors and titrant additions were 0.3 nm and 0.25 µL, respectively. The instrument was also equipped with a Peltier Sample Cooler (mod. F-3004) controlled by a Peltier Thermoelectric Temperature Controller model LFI-3751 (5 A–40 W). The whole system was controlled by the FluorEssence 2.1 software by Horiba Jobin-Yvon. The titrations were performed directly in a Hellma type 101-OS precision cell (Light Path 10 mm), where a magnetic stirrer and the anti-diffusion burette tip were placed in a position that would not interfere with the light beam. The automatic data acquisition (fluorescence intensity vs. λ(nm) for each titrant addition) was performed using the same FluorEssence 2.1 software. The excitation and emission bandwidths were both 5 nm. The protein samples were excited at 280 and 295 nm in order to characterize the possible different behavior of tryptophan and/or tyrosine residues. It was observed that both spectra were similar. The rest of the experiment was acquired by excitation at 280 nm and the emission spectra were recorded in the range of 300–400 nm. The potential interaction between nitrofurantoin and HSA was performed by fluorimetric titration. A 2.0 mL solution containing 1.5 × 10−5 mol/L) in a 20 mM sodium phosphate buffer (pH 7.4) containing nitrofurantoin at the same final concentration (1.5 × 10−5 mol/L) was titrated by successive additions of site markers solution (1.0 × 10−3 mol/L) to obtain overall site markers concentrations ranging from 0 to 9 × 10−5 mol/L. Fluorescence spectra were recorded at 310 K in the range of 300-400 nm with an excitation wavelength at 280 nm. The fluorescence of the ternary mixture as a percentage of the initial fluorescence was determined according to the method of Sudlow et al. [1 and F2 are the fluorescence of HSA−nitrofurantoin in the absence and in the presence of the site markers, respectively.The displacement studies were carried out utilizing different site markers . A solution of HSA (1.5 × 10w et al. :F2F1×100Docking calculations were carried out using AutoDock 4.2, and were graphically rendered by PyMOL 2.5 ,52. The The present experimental work describes, for the first time, the binding of nitrofurantoin to HSA. Our results may describe one of the mechanisms underlying the blood transportation of this compound through our body up to the kidney for its elimination. The binding reaction is spontaneous and involves hydrogen bond and hydrophobic interaction, as highlighted by the changes in the thermodynamic parameters. The interactions were confirmed through alterations in the UV−VIS absorption spectra of nitrofurantoin and albumin and the quenching of the intrinsic fluorescence of the protein, probably due to the hydrogen bond and apolar interactions with the nitro-substituted furan ring. In addition, the nitrofurantoin binding site is located in the hydrophobic pocket of subdomain IIA according to the site competitive study. Altogether, our results help to achieve a better understanding of the pharmacokinetic of nitrofurantoin, in order to design analogous molecules with a greater biological potential.


Histoplasmosis was much more common in the non-HIV pediatric population  compared to the HIV population. The non-HIV factors implicated were, childhood malignancies (n = 207), such as leukemias and lymphomas as well as their treatment, lung diseases (n = 7), environmental exposures and toxins (n = 224), autoimmune diseases (n = 12), organ transplants (n = 12), long-term steroid therapy (n = 3), the use of immunosuppressive drugs such as TNF-alpha inhibitors (n = 7) malnutrition (n = 12), histiocytosis (n = 3), hyperimmunoglobulin M and E syndromes , pancytopaenias (n = 26), diabetes mellitus (n = 1) and T-cell deficiency (n = 21). Paediatricians should always consider or rule out a diagnosis of histoplasmosis in children presenting with symptoms suggestive of the above clinical conditions. The classification of histoplasmosis as an AIDS-defining illness has largely attributed its occurrence in people to the presence of HIV/AIDS especially in Africa. Prior to the advent of the HIV/AIDS epidemic, many cases of histoplasmosis were documented both in the pediatric and adult population. Our review revealed 1461 reported cases of pediatric histoplasmosis globally in the last eight decades (1939–2021). North America ( Histoplasmosis is a systemic fungal infection occurring globally. It is endemic in the Ohio and Mississippi river valleys of the United States of America, India and Southeast Asia ,2. The cHistoplasma capsulatum. The two varieties pathogenic to humans are H. capsulatum var. capsulatum and H. capsulatum var. duboisii. The third variety, H. capsulatum var. farciminosum, is an equine pathogen [H. capsulatum proposed by Sepúlveda VE et al. showed that it is composed of at least four different cryptic species that differ genetically and also in virulence: Histoplasma capsulatum (Panama or H81 lineage), Histoplasma mississippiense (NAm 1), Histoplasma ohiense (NAm 2) and Histoplasma suramericanum (LAm A) [Histoplasma conidia [Histoplasmosis is caused by the dimorphic fungus, pathogen . Howeverense NAm  and Hist (LAm A) . Transpl (LAm A) ,12,13,14 conidia . ExtrapuLiterature searches for publications on histoplasmosis in children preceding February 2021 were performed using PubMed, Google Scholar, AJOL, Cochrane Library, Africa-Wide: NiPAD, CINAHL (accessed via EBSCO Host) databases and grey literature to identify all published papers regarding the topic. The main search comprised individual searches using detailed medical subject heading terms for histoplasmosis in children, including broad terms such as “case reports of histoplasmosis in children” and/or ‘diagnosis’ and ‘management’ of histoplasmosis in children. References in all relevant papers were also reviewed for additional publications  on histoplasmosis in children that may not have been published in the searched databases. No language restriction was applied. Only reports with patients’ country of origin identified were included. Publications reporting cases of histoplasmosis in individuals greater than 18 years of age were excluded from the review, as well as studies involving histoplasmosis in non-humans. Publications without abstracts were also excluded. The case definitions employed were based on an international consensus statement by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group (EORTC/IFICG) and the Mycoses Study Group (MSG) . Case ren = 1231), with 76.7% (944/1231) occurring in the USA. Very few cases (n = 4) in the pediatric population have been reported in Europe and were found in immigrants from endemic regions [n = 135), Africa (n = 65) and Asia (n = 26) respectively. More cases occurred in the non-HIV population compared to the HIV population, globally. The percentages of non-HIV patients with pediatric histoplasmosis across the various regions was 97.1% (1418/1461) and North America , South America , Africa , Asia  within each region, respectively, Histoplasma capsulatum var capsulatum (Hcc), while in Africa, it was largely due to Histoplasma capsulatum var duboisii (Hcd) . Most cases of disseminated histoplasmosis occurred in persons with compromised immunity  are frequently treated with steroids and other immunosuppressive agents including methotrexate. Because of the low doses used, opportunistic infections are not very common in association with autoimmune steroid or immunosuppressive therapy . HunstadPancytopaenia and defective phagocytic function usually in association with haemophagocytic lymphohistiocytosis (HLH) has been noted as a predisposing factor to pediatric histoplasmosis with Russ et al. reporting a case of histoplasmosis and HLH in a seven-month-old infant with vomiting and failure to thrive . The repTumor necrosis factor-alpha  inhibitors such as adalimumab, infliximab and etanercept are commonly used in the treatment of pediatric inflammatory bowel disease ,78. TheyHyperimmunoglobulin E syndrome also known as Job’s syndrome and hyperimmunoglobulin M syndrome are associated with defects in immune function specifically with defects in immunoglobulin levels, neutrophil chemotactic defects, defects in T-cell signaling and cytokine abnormalities ,83. ImpaThis study has revealed the high occurrence rate of histoplasmosis in the non-HIV pediatric population, a disease commonly described as an AIDS-defining infection. We have also documented the underlying condition more commonly associated with this disease in children. Misdiagnosis of histoplasmosis as tuberculosis due to their similar pattern of presentation has also been emphasized. Physicians managing children with risk factors highlighted in this study and presenting symptoms suggestive of TB should be screened to exclude or include histoplasmosis.


Delayed start-of-care nursing visits in home health care (HHC) can result in negative outcomes, such as hospitalization. No previous studies have investigated why start-of-care HHC nursing visits are delayed, in part because most reasons for delayed visits are documented in free-text HHC nursing notes.The aims of this study were to (1) develop and test a natural language processing (NLP) algorithm that automatically identifies reasons for delayed visits in HHC free-text clinical notes and (2) describe reasons for delayed visits in a large patient sample.This study was conducted at the Visiting Nurse Service of New York (VNSNY). We examined data available at the VNSNY on all new episodes of care started in 2019 . An NLP algorithm was developed and tested to automatically identify and classify reasons for delayed visits.The performance of the NLP algorithm was 0.8, 0.75, and 0.77 for precision, recall, and F-score, respectively. A total of one-third of HHC episodes  had delayed start-of-care HHC nursing visits. The most prevalent identified category of reasons for delayed start-of-care nursing visits was no answer at the door or phone , followed by patient/family request to postpone or refuse some HHC services , and administrative or scheduling issues . In 40%  of HHC episodes, 2 or more reasons were documented.To avoid critical delays in start-of-care nursing visits, HHC organizations might examine and improve ways to effectively address the reasons for delayed visits, using effective interventions, such as educating patients or caregivers on the importance of a timely nursing visit and improving patients’ intake procedures. Over the last several decades in the United States, recognition has been growing of the importance of post–acute care settings, including long-term care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities ,2. One sHHC consists of intermittent home visits conducted by skilled health care providers . Currently, over 6 million patients are admitted to more than 12,000 HHC agencies across the United States annually -9. DespiThe start-of-care nursing visit is one of the most critical steps of the HHC episode ,19. ThisThe CMS requires agencies to conduct a start-of-care visit within 48 hours of HHC referral or within 48 hours of the patient’s return home . HoweverNo previous study has investigated why start-of-care HHC nursing visits are delayed. One explanation may be that most delayed visit reasons are documented in free-text HHC nursing notes. Given a large volume of clinical notes , manual review is not feasible, calling for the use of data science methods.Fortunately, recent data science analytical techniques can extract insights from free-text documentation. Specifically, natural language processing (NLP) algorithms can be applied to large collections of clinical documents to identify a diverse range of concepts and extract meaning from documents . Often, An example of NLP algorithm use is the identification of social risk factors among patients discharged from hospitals using discharge summaries . The resIn HHC settings, previous applications of NLP focused on identifying patients who experienced falls , dementiThis study was conducted at Visiting Nurse Service of New York (VNSNY), the largest not-for-profit urban home care agency in the United States. The study research protocol was approved by the institutional review board of the VNSNY in October 2019.The study sample comprises all HHC patients admitted during the calendar year of 2019 following a hospitalization. The patients’ status of hospitalization prior to HHC was extracted from the M1000_3 variable on the Outcome and Assessment Information Set (OASIS), a patient-specific, standardized assessment required under Medicare HHC rules . The stuDates of hospital discharge and start-of-care HHC nursing visit were extracted from the OASIS. We calculated the difference in days between the following OASIS items: M1005: Inpatient Discharge Date and M0090: Date Assessment Completed. This study defined delayed start-of-care HHC nursing visits as visits conducted more than 2 days after hospital discharge. Approximately one-third  of episodes met this criterion.The electronic health record (EHR) had a standardized option that allowed HHC staff to document reasons for delayed visits. The standardized categories included no answer at the door or phone, administrative or scheduling issues, and patient/family request to postpone or refuse some HHC services.We extracted 118,767 clinical notes documented for HHC episodes with delayed visits. More than 1 note could be documented for an episode. There were 22 note types with the most common being narrative notes that included nursing and other HHC admission staff comments , initial welcome call notes that described the initial welcome telephone call to introduce HHC services to the patient , intake clinical comment notes that provided clinical details of the admitted patients , insurance and other additional information notes with information on patient insurance and additional clinical factors , telephone communication notes describing any phone contact between HHC staff and patients or family , and 17 other less frequent note categories .We developed an NLP algorithm using a regular expression technique  where alAs the first step of developing the NLP algorithm, the data preprocessing steps involved lowercasing, stripping (removing extra spaces), and removing special characters , ]). We did not remove stop words because they were important for identifying the reasons for delayed start-of-care. For example, negation indicators (such as no and not) or auxiliary words  were important for identifying if a patient requested to postpone the HHC services. We also did not perform lemmatization or stemming because keeping the original form of words, particularly the verbs, was important for identifying a pattern of late visit.As the second step of developing the NLP algorithm, we created regular expression rules to capture language describing patient or family requests to postpone HHC or refuse some HHC services. This included the following phrases: “pt declined VNS visit today,” “patient refused visit and asks for visit tomorrow,” “daughter asks to reschedule SOC for Friday.” These phrases have some word patterns, such as “patient/pt/family refused,” “asks for visit tomorrow,” and “reschedule SOC for Friday,” that were used to develop regular expression rules. To evaluate the accuracy of our NLP algorithm, we extracted 100 clinical notes from each of the 22 note types, resulting in 2200 clinical notes. Each note was reviewed independently by 3 HHC experts, who labeled the note with 1 or more of the 3 delayed start-of-care HHC nursing visit categories, where applicable. The experts included a PhD-prepared registered nurse, a social worker, and an experienced research analyst. There was a high level of initial interrater agreement between the experts (κ>0.8) . DisagreWe applied our NLP algorithm on the testing set and calculated the accuracy of NLP in identifying reasons for delayed visits. For each category of delayed visit reasons, we calculated the precision , recall , and F-score . These metrics vary between 0 and 100%, with higher values indicating better NLP algorithm concept identification performance; values above 75% indicate high performing NLP algorithms.The majority of patients admitted to VNSNY were aged over 65 years . Females comprised a larger fraction of the patient population compared to males. The proportion of non-Hispanic White patients was significantly higher than that of other races. Hypertension  was the most common disease among patients, followed by diabetes  and cancer . The majority of the patients  could receive support from their family members or their caregivers.The overall accuracy of NLP in detecting language related to reasons of delayed visits was high, as reflected by the total F-score of 0.77 . When apAlthough the total F-score of the NLP algorithm for identifying the reason of delayed start-of-care is promising, it also implies that the algorithm could not capture all variations for delayed start-of-care in clinical notes. For example, it did not identify the following notes indicating that the patient postponed the start-of-care: (1) “Pt will return call from [nurse], he prefers the soc after 3 (PM),” (2) “Spoke with patient’s caregivers, stated that they are moving to a new apartment and the patient would like to have soc in another time.”In total, 16,244 HHC episodes had a delayed start-of-care HHC visit. Among all 16,244 episodes with a delayed start-of-care nursing visit, 3097 (19.1%) had reasons for delayed start-of-care documented using standardized documentation. Of the 3097 cases with documentation, 5484 unique reasons for delayed start-of-care HHC nursing visits were found (a single HHC episode could have more than 1 reason documented).Overall, 72.2% of the delayed visit reasons , followed by “patient/family request to postpone or refuse some HHC services”  and “administrative or scheduling issues” .Further analysis showed that in more than 40% of episodes with delayed start-of-care HHC nursing visits, 2 or more reasons were documented. The analysis of cooccurrence of reasons for delayed start-of-care HHC nursing visits  indicateThis is the first study we are aware of that examines reasons for delayed start-of-care HHC nursing visits in a large population of HHC patients. Identifying reasons for delayed start-of-care is critical due to the association between delayed care and negative outcomes. The majority of patients requiring HHC are clinically complex and vulnerable older adults who were discharged from hospitals with a need for immediate post–acute care . DelayedThe findings of this study indicate that when a reason is provided, most reasons for delayed start-of-care HHC nursing visits  are documented exclusively in narrative clinical notes. Large-scale analysis of thousands of clinical notes can now be accomplished via innovative data science methods, including NLP.We developed and tested an NLP algorithm to identify patterns of documented delayed start-of-care HHC nursing visit reasons in clinical notes. The NLP algorithm achieved high accuracy in identifying documented reasons when tested on an expert-reviewed sample of clinical notes. NLP algorithms have a wide range of potential applications in extracting meaningful patterns from EHR clinical notes . We beliOur findings indicate that the most prevalent category of delayed start-of-care HHC nursing visits was “no answer at the door or phone.” Potential explanations include having incorrect phone or address information transmitted to the HHC organization, last minute decisions by patients to recover in a location other than their own home, and a lack of communication between the HHC organization and the patient about the patient’s availability. To address this issue, referring hospital clinicians may need to discuss the timing and importance of the first visit with the patient and family and obtain accurate contact information. In addition, it may be necessary to develop a clear communication plan with the HHC agency in the process of transferring the patient from the hospital to the HHC setting.Previous studies -42 and oThe second most prevalent reason for delayed start-of-care HHC nursing visits was “patient/family request to postpone or refuse some HHC services.” Although some related care delays are probably unavoidable, referring physicians and HHC clinicians may need to spend more time articulating the importance of start-of-care HHC nursing visits. Several recent studies indicate many patients may not understand the value of HHC and refuse care. A recent national study found that more than half of the patients referred to HHC from hospitals never receive HHC services . AnotherIn about 20% of HHC episodes, delayed start-of-care was due to “administrative or scheduling issues.” Some of the specific issues were inadequate or incomplete insurance coverage, lack of forms and documents, and a lack of available HHC nurses to complete a start-of-care visit on time. To resolve these issues, HHC organizations may need to develop better and more streamlined patient intake procedures and identify several ways to adjust schedules when a nurse calls in sick or is otherwise unavailable to take on new cases.Our results indicate that in more than 40% of HHC episodes, there were 2 or more reasons for delayed start-of-care HHC nursing visits. The most common cooccurring reasons indicated in about 20% of HHC episodes were “no answer at the door or phone” and “patient/family request to postpone or refuse some HHC services.” In a relatively small number of cases (7%), patients had a combination of all 3 reasons for delayed start-of-care HHC nursing visits. We hypothesize that patients with cooccurring reasons might be more likely to have a delayed start-of-care HHC nursing visit due to the challenges of addressing all reasons of delays in this group of patients. Clinicians may decide to prioritize patients with cooccurring reasons for appropriate interventions to reduce the likelihood of delayed start-of-care. The patient’s demographic and clinical factors might affect their risk for a delayed start-of-care HHC nursing visit. Identifying the relationship between these factors and reasons for delayed visits may help clinicians target patients at high risk for delayed visits with specific interventions. This is an area that requires further investigation.The findings of this study provide insight into the application of NLP techniques to identify reasons for delayed start-of-care in HHC agencies and potential interventions to address the delays and avoid subsequent negative outcomes. HHC administrators may begin considering the use of NLP techniques to analyze the HHC nursing visits for patients that were seen later than 48 hours post–hospital discharge date to identify the reasons for delays and potential interventions. Obtaining and maintaining accurate patient contact information, educating patients about the importance of timely HHC services, and improving the procedures of patient intake and the scheduling system are among the interventions we suggested to reduce the risk of delayed start-of-care due to the following reasons, respectively: “no answer at the door or phone,” “patient/family request to postpone or refuse some home health care services,” and “administrative or scheduling issues.”The findings of this study should be considered in light of several limitations. First, the data set was from a single HHC agency located in the northeast United States. Although the HHC agency is large, its services are limited to individuals residing in a particular catchment area. Therefore, the reasons for delayed visits may not be generalizable to HHC agencies in other locations. Second, the available data did not have information on the hour of discharge from the hospital, so the analysis was based on days, not hours as in the CMS regulations. Third, the NLP algorithms developed in this study had a total precision of 0.8 and recall of 0.75. These findings indicate that some reasons for delayed start-of-care HHC nursing visits identified by NLP were incorrect due to algorithm errors. It is unclear if additional reasons would have been identified if more information on these episodes was provided.To avoid delays in critical start-of-care nursing visits, HHC agencies and hospitals should consider examining and improving accurate patient or family contact information collection. In addition, HHC agencies should consider providing targeted education about the importance of the early initiation of HHC services to reduce patient and family refusals and/or requests to postpone care. Finally, HHC agencies should make efforts to reduce administrative and scheduling issues to enable timely and effective care.


Thus, producing rice based on quality assessment can improve food security and its sustainability.Rice market efficiency is important for food security in countries where rice is a staple. We assess the impact of rice quality on rice prices, food security, and environmental sustainability in Bangladesh. We find that while price varies as expected for most quality attributes, it is unaffected by a broken percentage below 24.9 percent. This reveals a potential inefficiency, considering the average 5 percent broken rate observed in the market. An increase in the broken rate of milled rice within the limits supported by our findings can,  Oryza sativa L.) is the main food for over half of the world population [Rice  in 2020/2021 . There aSome 40 percent of the rice produced in Bangladesh is for home consumption and processed using primarily home-made tools such as Dhekis , or custThere rice market in Bangladesh is highly segmented, with different types of rice having distinct regional and socioeconomic markets and carrying notably different prices. One common classification includes fine rice (length/width ratio of more than 3), coarse (bold) rice (length/width ratio < 2.1), and aromatic rice .There is growing pressure to improve rice productivity in Bangladesh to cope with increases in rice demand and shrinking production resources . Rice productivity increased by around 1 percent annually from an average of 4.07 metric tons (MT) per hectare in 2010 to 4.51 MT/hectare in 2020 , in partGlobally, consumer preferences for rice are heterogenous, and therefore the value attached to specific attributes varies geographically and by the socio-cultural context in which rice consumption is embedded. There is growing evidence, primarily from Asia and Africa, that indicates consumers are increasingly aware of rice quality, even amongst low-income households , 18–23. Short and bold grain rice are considered fine quality rice in the southern parts of India  and Sri Lanka , while cThe data used in this study consists of 300 milled rice samples collected from ten different retail rice markets across urban Dhaka, Bangladesh, in September 2020. To capture potential price and quality heterogeneity due to differences in household socioeconomic status , the markets were selected from different neighborhoods of Dhaka, which were in turn chosen based on the average poverty headcount ratio of each respective neighborhood as estimated by the World Bank . The marThe rice samples were processed to ascertain their quality considering the following intrinsic quality attributes: broken percentage, chalk percentage, color, length, width, homogeneity , and parboiling. The Vibe QM3 Rice Analyzer was used to obtain quality attributes and was calibrated to the Bangladeshi standard for milled rice (Supplementary file A) developed by the Bangladesh Standards and Testing Institution .Broken percentage is defined as:WBi and WHi are the weight of broken and whole rice in sample i, respectively.Milled rice is composed of head rice, defined by the Bangladeshi rice standard as a kernel whose length is at least 8/10 of the average length of the corresponding whole kernel, and broken rice, defined as a kernel whose length is less than 8/10 of the average length of the corresponding whole kernel . The varChalk percentage is defined as:WCi is the weight of chalk rice in sample i.The chalk percentage is defined as the weight of rice kernels with half or more of their area opaque and chalky relative to the weight of the sample . The varColor is estimated as:Color is measured in the CIELAB color space. CIELAB is made up of three channels: L* represents the lightness value of the color; a* represents green or red respectively; and b* measures blue as negative and yellow as positive value. Length and Width represent the average length and width across all kernels n in sample i.The size of rice is measured by the length and width of the kernels (in millimeters), and consequently variables i is measured by the length to width ratio (LWR) as follows:Finally, the shape of rice in sample .1) rice .Homogeneity was specified a a binary variable equal to 1 if the sample was mixed, and zero if it was classified as either long-, medium-, or short-grain rice.Rice homogeneity refers to whether the rice sample can be classified as of one type , or a mix of different types. We adopted USDA’s definition of milled rice classes , accordiDouble-boil and Single-boil, to identify whether the rice was single- and double-boiled rice. In Bangladesh, single-boiled rice is produced following the traditional three-step process of (1) soaking, (2) steaming, and (3) drying paddy rice, while double-boiled rice is steamed twice (once before and once after soaking) and then dried, and hence follows a four-step approach [Finally, we created two dummy variables for parboiling, approach .Vendors identified all the rice samples collected for this study as domestic rice, which is expected considering that Bangladesh was 97.2 percent rice self-sufficient from 2015–2020 .We conducted a piecewise analysis to ascertain if the effect of an independent variable  on rice price varies over the observed ranges . This isPi represents the price paid by consumer i, iX is a vector of rice quality attributes, and εi is the error term. The model was estimated with and without market fixed effects to account for differences across the markets surveyed. Based on the variables defined above, the econometric equation is defined as:Price, and the independent continuous variables LWR and Color are expressed in logarithm. We conducted a piecewise analysis for broken percentage , while Color, LWR, Double-boil, and Single-boil have positive coefficients. We hypothesize that the variable Homogeneity is positively correlated with the market price of rice, and thus has a positive coefficient. Finally, we expect that, everything else equal, market prices would be negatively correlated with the income level in the selected markets.Based on the literature on rice quality preferences in Bangladesh, we expect that variables The broken percentage ranged from 0.43 percent to 46.15 percent, with an average of 5.35 percent. The average broken percentage is considered low by international trade standards, given that rice with 5 percent or less broken is typically classified as high-quality rice. Based on the Bangladeshi standard for milled rice , a 5 perThe chalk percentage ranged from 0 percent to 89.56 percent, with an average of 12.56 percent. The large variability is partially explain by the fact that our samples include parboiled rice, which has a low chalk rate as the parboiling process decreases chalkiness . The aveColor ranged from 56.86 to 79.61, with an average of 68.76. Regarding rice size and shape, the average length, width, and LWR were 5.07 mm, 1.98 mm, and 2.62, respectively, which according to the Bangladesh standard for milled rice  correspoThe price and broken percentage of milled rice vary significantly  across markets . The aveBroken percentage 1, including observations with a broken percentage less than or equal to 24.94 percent, and zero otherwise; and Broken percentage 2, including observations with a broken percentage greater than 24.94 percent, and zero otherwise.The results from the piecewise analysis for broken percentage  highlighBroken percentage 1) has no significant impact on rice prices, whereas it modestly but significantly (p<0.05) decreases the price of rice at rates above 24.9 percent (variable Broken percentage 2). To illustrate, the results from Model 1 and Model 2  suggest that a 1-point increase in the broken percentage above 24.9 reduces the price of rice by 0.25 percent and 0.20 percent, respectively. The findings of this study suggest that the impact of broken rice differs depending on its level (above and below 24.9 percent), and if prices truly reflect consumer preferences, that consumers are indifferent about the amount of broken rice up to a rate of 24.9 percent. These results are in line with those by [The results from both models suggest that broken percentage at a rate below 24.9 percent  suggest that a 1-point increase in the chalk percentage reduces the price of rice by 0.16 percent and 0.15 percent, respectively. These significant but marginal impacts reveal that consumers in Bangladesh are largely indifferent to chalkiness, which may be influenced by the fact that most of the rice consumed in Bangladesh is parboiled, which changes the color of rice from white to more yellow and changes the visual aspect of chalk rice. Previous research also finds a modest impact of chalkiness, namely, that a 1-percent increase in overall chalkiness reduces rice price by 0.10 in Bangladesh [Chalkiness was estimated to have a small but significant (p<0.01) impact on rice price in both models. The results from Model 1 and Model 2 (coefficient of -0.0016 and -0.0015 for Color), the coefficients can be interpreted as elasticities. Thus, a 1-percent increase in color results in a 0.412 percent and 0.319 percent increase in the price of rice in Model 1 and Model 2, respectively. The positive relationship between color and price is supported by the previous findings [Color has a positive and significant (p<0.05) impact on price in both models. Since color is specified in a log form  has a significant (p<0.001) and positive impact on rice price, increasing it by 0.224 percent and 0.230 percent for every 1-percent increase in LWR in Model 1 and Model 2, respectively. These findings align with previous results that suggest that Bangladeshi consumers value slenderness [LWR has a positive and large impact on rice prices in rural and urban Bangladesh [The shape of rice , the results suggest that rice mixes have a positive  and significant (p<0.001 for both models) impact on rice prices relative to pure types . To our knowledge, this is the first study objectively assessing this attribute, but the results are counterintuitive since we expected that rice mixes would have an inferior appearance and be priced lower than more homogeneous-appearing rice.Regarding the homogeneity of rice  lower in the four low-income markets of Thathari Bazar/Old Dhaka (variable Market 7), Jatrabari (variable Market 8), Adabor (variable Market 9), and Khilgaon (variable Market 10), than in Dhanmondi (Market 1).To help understand the impact of the rice quality attributes on the price of rice in Bangladesh, we estimate marginal effects using the estimates from Model 1 and Model 2  by estimLWR has the largest marginal effect, implying that the price for rice with a low (high) LWR of 1.59 (3.90) is 10.6 percent lower (9.6 percent higher) than the average price. Homogeneity also has a significant  marginal effect, and requires a 9.3 percent discount if it is a homogeneous sample and a 5.9 percent premium if it is mixed relative to the average market price. Changes in the chalk percentage over the range observed in this study affect rice price from an 11.3 percent discount for rice with a chalk percentage of 89.56 to a 2.0 price premium for rice with a chalk percentage of zero. Finally, a broken percentage above 24.94  can change rice price from a discount of 10.9 percent for the highest broken rate observed in this study (46.15 percent) to 0.3 percent premium for rice with exactly 24.94 percent broken rate (Broken percentage 2 = 0).Looking at the marginal effects from Model 1 , LWR hasThe fact that the broken percentage below 24.9 percent was estimated to have no impact on price, while the average broken rate in the market is 5 percent , could be seen as a lost economic opportunity, since mixing more broken rice into milled rice could increase revenues due to the fact that broken rice mixed and sold as milled rice (harmonized system (HS) code 100630) carries a higher price than if sold as 100 percent broken (HS 100640).We claim that such quality mismatch is also a lost opportunity in the fight to improve food security in an environmentally sustainable way, because it reduces the supply of rice for food  produced per unit of input  and creates a surplus of broken rice used for other non-human purposes. Directing the use of broken rice for food by increasing the broken percentage of the milled rice sold in the market reduces leakages/inefficiencies (broken rice leaving the food system and used for other purposes) and improves the efficiency of producing rice rations, which leads to greater supply of rice for food per metric ton of rice.Kharif crop [Assuming a 52.5/70 quality of paddy rice, 4.57 MMT of paddy rice produce 3.20 MMT of milled rice with a broken rate of 25 percent by consuming all broken rice (zero broken rice surplus), which is enough to feed 22.12 million people per year in Bangladesh at the average per-capita consumption of 144.5 kg/year [To support the claim above, we need to first estimate the potential volume of rice suitable for quality grading based on broken percentage. Around 40 percent of the rice produced in Bangladesh is kept on-farm for self-consumption and processed using primarily home-made tools such as Dhekis . The remrif crop , which r kg/year  (Table 4 kg/year . The finAnother way of looking at the efficiency gain of producing rice rations (per unit of paddy rice) due to increasing the broken rate of milled rice, is by estimating the rice area saved to achieve a given number of rice rations. At the average yield of 4.44 metric tons/hectare observed in Bangladesh in 2016–2019 , we estiThe ability to produce the same number of rice rations with fewer production inputs improves the environmental sustainability of food security in two main ways. First, it reduces the environmental footprint of producing rice rations. Using a life cycle analysis (LCA) approach, it was estimated that the global warming potential (GWP) per kilogram of rice produced in Bangladesh across the three rice seasons  and two technologies  ranges from a low of 1.06 to a high of 3.37 kg CO2 equivalent for Aman high yielding varieties and Aus traditional varieties, respectively . We weigSecond, the higher efficiency in the production of rice rations lowers the pressure on natural resources, mainly arable land and fresh water, and thus counters the potentially negative impact of climate change on rice production. Bangladesh is vulnerable to climate change due to its low elevation, high population density, poor infrastructure, and its dependency on agriculture. Previous research  estimateKharif crop [The implications discussed above rest on several assumptions, including the quality of milled rice produced in Bangladesh, which is assumed to be 52.5/70, and equivalent to the procurement standard used by the Food Corporation of India for “Grade A” rice in the 2020–21 rif crop . Improverif crop , the couThe rice sector in Bangladesh is a major contributor to the agricultural economy, and is the main staple food for nearly every household. The dominance of rice in the agricultural production and consumption matrix heightens the importance of ensuring that markets work efficiently in the sense of pricing rice according to the quality offered so that consumers can choose the rice options that best fits their preferences and budgets, and the supply chain can properly source and generate the rice to meet that demand. This study estimates the economic value of the selected intrinsic rice quality attributes deemed of importance in Bangladesh, and the food security and environmental implications of producing milled rice with the quality characteristics indentified in this study relative to what is currently offered in the market.These results suggest that the broken percentage, chalk percentage, LWR, color, and homogeneity of rice all have a statistically significant impact on rice prices. The shape of rice, represented by the LWR, has the largest impact on rice price, followed by homogeneity. The chalk percentage has a modest impact, while the broken percentage is statistically significant only when rates go above 24.94 percent, and even then it has only a marginal impact on rice prices.The fact that the broken rate has such a minor impact on rice prices highlights a potentially relevant market inefficiency, because broken rice traditionally carries a price discount vis-à-vis whole rice that in this case is not being transmitted to consumers. This disconnect between brokens produced and brokens marketed is problematic from a food security perspective in two possible ways. First, it may mean that the market is overpricing rice with high percentage of broken rice to the detriment of consumers that prefer cheaper rice with higher brokens but are forced to pay a higher price for higher quality rice. Second, the striking difference between the (low) average broken percentage among the rice samples used in this study and the threshold broken percentage of 24.94 at which rice prices react to the broken percentage may mean a potential missing opportunity for selling more broken rice for human consumption.Pricing rice accurately based on the broken percentage could improve food security by allowing consumers to either (1) afford to buy more rice with a given budget, or (2) improve the intake of other food items by buying the same amount of rice for less. Furthermore, our results suggest that there is room to increase the broken rate of the milled rice processed by modern mills, which amount to around 8.82 percent of the total rice production. We show that an increase in the broken rate from the observed 5 percent to 25 percent broken rate impied by a 52.5/70 quality paddy rice similar to the standard used in neighboring India can lead to substantial reductions in greenhose gases and help offsetting some of the potential negative impacts of climate change, such as rising sea levels.Despite the importance of rice as a global staple, assessments of the impact of rice quality attributes on consumer demand are lacking. We argue that studies such as this offer an opportunity to ascertain how the market prices rice based on quality because the framework is easy and affordable to implement, and can provide valuable information to guide marketing and policy decisions, such as the development of grading standards, investment in production and milling technologies, and research and extension programs and policies to foster a production sector catered to the demands of the market. Importantly, this study helps fill the important void in the literature pertaining to how rice quality preferences impact regional food insecurity as well environmental suustainability.This study has several limitations, including the lack of respondents’ socioeconomic information and the exclusion of other rice quality attributes that may drive consumers’ choices. Previous studies show that socioeconomic conditions affect consumer preferences for rice across South and Southeast Asia , 20, andNotwithstanding these limitations, we believe this study shows a simple and low-cost approach to ascertain the potential inefficiencies in the rice market that could be undermining progress towards improving food security and sustainability. Methodological aspects, such as collection of socioeconomic information from consumers, selection of markets, and even quality attributes to include, must be carefully considered to make sure the results are valid for the market of interest.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(XLSX)Click here for additional data file.