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+{"text": "APOE) \u03b52/\u03b53/\u03b54 polymorphism, which also is a significant predictor of variation in the risk of coronary heart disease (CHD) and CHD death. Here, we test the hypothesis that the APOE polymorphism may modulate the cholesterol-raising effect of coffee.The response of serum cholesterol to diet may be affected by the apolipoprotein E  and women (78%) aged 29\u201365 years, took part in a study with four intervention periods: 1 and 3) a coffee free period of three weeks, 2 and 4) 600 mL coffee/day for four weeks.APOE \u03b52 positive individuals had significantly lower total cholesterol concentration at baseline , but the cholesterol-raising effect of coffee was not influenced significantly by APOE allele carrier status.APOE \u03b5 2 allele is associated with lower serum cholesterol concentration. However, the APOE polymorphism does not seem to influence the cholesterol-raising effect of coffee.The  APOE gene sequence results in the 3 common alleles , which can produce 6 different genotypes . The \u03b52, \u03b53 and \u03b54 alleles encode three distinct forms of apoE  and have approximate frequencies of 8%, 77%, and 15%, respectively, in white populations [APOE \u03b52 allele display lower levels of plasma cholesterol compared with individuals carrying the APOE \u03b53 allele, whereas individuals with the APOE \u03b54 allele show higher levels of plasma cholesterol, especially LDL-cholesterol [APOE \u03b53/\u03b54 and \u03b54/\u03b54 genotypes absorb cholesterol effectively and have higher non-fasting serum triglyceride values than \u03b54 negative individuals [APOE gene is shown to be a significant predictor of variation in the risk of coronary heart disease (CHD) and CHD death [APOE \u03b54 allele. The APOE \u03b54 allele is also considered a strong risk factor for Alzheimer's disease [Apolipoprotein E (apoE) is a structural component of triglyceride-rich lipoproteins, chylomicrons, very-low-density lipoproteins (VLDL), and high-density-lipoproteins (HDL) . VariatiHD death , but theHD death . Both thHD death  and the HD death  suggest  disease -16.APOE \u03b52/\u03b53/e4 polymorphism.The serum cholesterol-raising effect of coffee is due to the diterpenes kahweol and cafestol . EarlierThe study was organised as a prospective, controlled study with four consecutive trial periods. The first and third periods were 3 weeks of total coffee abstention. The second and fourth period consisted of 4 weeks with the subjects consuming 600 mL filter brewed coffee/day.The main outcome or effect variable was total serum cholesterol and the effect was assessed as the difference between the measurements at the beginning and the end of the coffee free periods (coffee abstention) and the difference between measurements at the beginning and at the end of the four weeks of coffee consumption Figure . Trial dParticipants were recruited by advertising in Gothenburg's major newspaper. Inclusion criteria were age-range 30\u201365 years, free from clinically recognized chronic diseases, such as cardiovascular diseases, cancer, renal disorders, liver disease and diabetes mellitus. The participants were required to be free from anti-epileptic or cholesterol lowering drugs, and had been using coffee on a regular basis for at least five years and were currently non-smokers (at least for the last six months).During the coffee drinking periods the participants were instructed to drink about 600 mL filter brewed coffee/day (4 cups), according to standardised measures. The coffee was provided to guarantee that they were all exposed to the same brand and quality of filter brewed coffee. All participants also got the same kind of standardised coffee filter and measuring spoon.The coffee filters used were of the brand Euro-Shopper, made by Indupa N.V., Zaventem, Belgium. Divergence from the 4 cups was reported. The participants were allowed to drink tea and other caffeine containing beverages during the coffee-free periods.Non-fasting blood samples were drawn at inclusion and at three, seven, ten and fourteen weeks after start of the study. Prior to analysis, prepared serum was stored at -70\u00b0C.2) was recorded once during the study. Blood pressure was recorded by manual device and EKG and heart rate were recorded at all five visits.The blood samples were analysed for blood lipids  (Lp(a)) and urate in serum. Serum cholesterol and triglycerides were determined by an enzymatic procedure on a Hitachi 917 analyzer. HDL cholesterol was determined enzymatically after precipitation of VLDL, LDL and chylomicrones by \u03b1-cyklodextrinsulphate and dextransulphate. Determination of Lp(a) was done by the method Tint Elize Lp(a) of Biopool International. Serum urate was analysed by Hitachi 917 autoanalyser. Body Mass Index , but not in the \u03b52-positive group  and coffee consumption prior to the study (Table Coffee consumption resulted in a significant cholesterol increase in the \u03b5The dietary survey did not reveal any important changes during the four intervention periods . Coffee APOE genotypes differ in the absorption efficiency of cholesterol from the intestine, in the synthesis rates of cholesterol and bile acids, and in the production of LDL apoprotein B [APOE e2/e3/e4 polymorphism [APOE polymorphism [APOE \u03b54 allele. Here, we investigate for the first time the possible influence of the APOE polymorphism on the cholesterol-raising effect of filtered coffee.Subjects with different rotein B ,26. Thismorphism ,28. One APOE \u03b54-positive individuals did not differ significantly from \u03b54-negative individuals with regard to baseline cholesterol concentration or coffee-induced changes in cholesterol concentration. However, we confirm that \u03b52-positive individuals display significantly lower cholesterol levels at baseline than \u03b52-negative individuals. A tendency was seen that \u03b52-positive individuals might be partly protected from the cholesterol increasing effect of coffee consumption. This was, however, only seen in the first trial period and will require further investigations. In conclusion, the APOE \u03b52/\u03b53/\u03b54 polymorphism is not a strong modulator of the cholesterol-increasing effect of coffee. Other genes should be discussed and further investigation is needed to see if there is a genetic factor in the cholesterol-raising effect of coffee."}
+{"text": "However, the model is complicated, and it is not clear which specific DNA sequence properties are most important for intrinsic nucleosome-forming preferences.The relative preference of nucleosomes to form on individual DNA sequences plays a major role in genome packaging. A wide variety of DNA sequence features are believed to influence nucleosome formation, including periodic dinucleotide signals, poly-A stretches and other short motifs, and sequence properties that influence DNA structure, including base content. It was recently shown by Kaplan et al. that a probabilistic model using composition of all 5-mers within a nucleosome-sized tiling window accurately predicts intrinsic nucleosome occupancy across an entire genome in vitro and in vivo in a manner comparable to the Kaplan model. G+C content and frequency of AAAA are the most important features. G+C content is dominant, alone explaining ~50% of the variation in nucleosome occupancy in vitro.We find that a simple linear combination of only 14 simple DNA sequence attributes  explains nucleosome occupancy Our findings provide a dramatically simplified means to predict and understand intrinsic nucleosome occupancy. G+C content may dominate because it both reduces frequency of poly-A-like stretches and correlates with many other DNA structural characteristics. Since G+C content is enriched or depleted at many types of features in diverse eukaryotic genomes, our results suggest that variation in nucleotide composition may have a widespread and direct influence on chromatin structure. In the in vivo,4. Activin vivo-7, presuS. cerevisiae, studies examining the relative incorporation of yeast genomic DNA into nucleosomes in vitro have demonstrated that nucleosome depletion at promoters is to a large extent programmed into the DNA sequence[in vivo. Therefore these results also indicate that the sequence preferences of nucleosomes are likely to be broadly conserved across eukarya.In  sequence,9. These sequence or humanin vivo and in vitro experiments[in vivo[in vivo correlates with and can be predicted by base composition (G+C content)[in vivo nucleosome occupancy, and did not directly demonstrate intrinsic nucleosome sequence preference.To fully understand the function and evolution of gene regulation and genome packaging, it will be essential to understand the sequence preferences of nucleosomes. A variety of sequence cues have been shown to influence nucleosome sequence preference. These include nucleosome positioning,11 and eperiments,21 and ts[in vivo,23. Howes[in vivo,24-27, as[in vivo. Some of content),28 and o content), many ofin vitro. The Kaplan model should inherently capture the effects of both base composition and aspects of large-scale structural properties which are thought to depend primarily on dinucleotide content[Kaplan et al. showed re content. Howeverin vitro data, it performs comparably or better than the best previous models on in vivo data in both yeast and C. elegans. The 14 feature model is heavily dependent on G+C and poly-A content, with G+C having the highest independent correlation with measured nucleosome occupancy. We suggest possible explanations and implications of the strong association between G+C content and intrinsic nucleosome occupancy.Here we used Lasso, a lineain vitro nucleosome data of Kaplan et al.[Table S1 , including representatives of all categories (a-d) above . In each case, Lasso assigned nonzero weights to a similar set of features [-308). The Kaplan model has a correlation coefficient of 0.74 over the same test data. Thus, the 14 feature model encapsulates the vast majority of the information in the Kaplan model. Indeed, the correlation between the 14 feature model and the Kaplan model over the entire yeast genome is 0.88 , independently of all other features . We note that the Kaplan model weights for individual 5-mers also scale highly with G+C content  and that the scores assigned by the Kaplan model to 147-base windows across the yeast genome correlate highly with G+C content , both correlate well with G+C content when calculated as an average over a tiling window using dinucleotide tables  is a major component. G+C content may be a dominant feature because it correlates with many structural properties of DNA, and also reduces the frequency of poly-A-like stretches. Since local variations in G+C content occur at many types of features in diverse eukaryotic genomes, our findings suggest that nucleotide composition may have a widespread and direct influence on chromatin structure.in vitro and in vivo)[2 scale. We also used the in vivo nucleosome occupancy measurements from a tiling array study in yeast[in vivo map of nucleosome occupancy in C. elegans[2 ratio between the basepair's total occupancy and the mean genomic average occupancy. Then, we set the genomic average to zero by subtracting the new genome-wide mean from each basepair.We converted the average nucleosome occupancy measurements from yeast ( in vivo) to log2 . elegans using bo. elegans. For thi2 in vitro nucleosome occupancy data), Lasso generates a linear model \u0177 = \u03b2 x1 + \u03b2 x2 + ... \u03b2 xn, where the output \u0177 is the nucleosome occupancy prediction for a given base position, and \u03b2 are the weights for each feature (x1..n), calculated at that position. The Lasso algorithm imposes a constraint on the sum of the weights, such that only the most important features are given non-zero weights. Input features are listed in Table 2H42 tetramer of the histone octamer[in vitro[We downloaded a MATLAB version of the Lasso algorithm,40. Give[in vitro. The frein vitro occupancy, and used the presence or absence of the sequence feature to define positive and negative instances. For the base composition and dinucleotide feature models, we calculated the Pearson correlation to the measured in vitro nucleosome occupancy, and retained those with correlation > |0.10|. We then ran Lasso on the selected sequence features, training on 1,000,000 randomly selected data points from chromosomes 1-9 (or other sets of chromosomes as indicated) which had been standardized to have mean zero and unit variance  and selected the optimal weights by means of 10-fold internal cross validation. The 14 feature linear model is as follows  resulted in more stable results. We therefore selected input features as follows: for 4-mer frequency and nucleosome excluding/positioning motifs, the AUROC (area under the receiver operating curve) \u22640.45 and AUROC > 0.54. To calculate the AUROC for each sequence motif, we first sorted each 150-base sequence by Intrinsic sequence preference = 1.67175 \u00d7 G+C content + 0.145742 \u00d7 propeller twist + 1.31928 \u00d7 slide - 0.10549 \u00d7 freqAAAA - 0.07628 \u00d7 freqAAAT - 0.03006 \u00d7 freqAAGT - 0.05055 \u00d7 freqAATA - 0.02564 \u00d7 freqAATT - 0.02154 \u00d7 freqAGAA - 0.03949 \u00d7 freqATAA - 0.02354 \u00d7 freqATAT - 0.03214 \u00d7 freqATTA - 0.03314 \u00d7 freqGAAA - 0.0334 \u00d7 freqTATA + 1.788022Where 4-mer occurrence is calculated in 150 bp windows, and G+C content, propeller twist and slide are calculated in 75 bp windows as described above. Propeller twist and slide were calculated as averages over all dinucleotides from tables found in:S(i) is the structural feature  score for the dinucleotide at position i.Where http://srs6.bionet.nsc.ru/srs6bin/cgi-bin/wgetz?-page+LibInfo+-newId+-lib+PROPERTY:For propeller twist and slide, the full equations are (from the PROPERTY databasehttp://srAverage propeller twist = (-17.3 \u00d7 freqAA - 6.7 \u00d7 freqAC - 14.3 \u00d7 freqAG - 16.9 \u00d7 freqAT - 8.6 \u00d7 freqCA - 12.8 \u00d7 freqCC - 11.2 \u00d7 freqCG - 14.3 \u00d7 freqCT - 15.1 \u00d7 freqGA - 11.7 \u00d7 freqGC - 12.8 \u00d7 freqGG - 6.7 \u00d7 freqGT - 11.1 \u00d7 freqTA - 15.1 \u00d7 freqTC - 8.6 \u00d7 freqTG - 17.3 \u00d7 freqTT)/75Average slide = (-0.03 \u00d7 freqAA - 0.13 \u00d7 freqAC + 0.47 \u00d7 freqAG - 0.37 \u00d7 freqAT + 1.46 \u00d7 freqCA + 0.6 \u00d7 freqCC + 0.63 \u00d7 freqCG + 0.47 \u00d7 freqCT - 0.07 \u00d7 freqGA + 0.29 \u00d7 freqGC + 0.6 \u00d7 freqGG - 0.13 \u00d7 freqGT + 0.74 \u00d7 freqTA - 0.07 \u00d7 freqTC + 1.46 \u00d7 freqTG - 0.03 \u00d7 freqTT)/75C. elegans genomes using the model scored on 150-base windows surrounding each data point in both in vitro and in vivo nucleosome maps [We predicted nucleosome occupancy in yeast and ome maps ,34 at 1 http://genie.weizmann.ac.il/software/nucleo_exe.html[occ or \"average occupancy\" measure. For other models[C. elegans chrIII, and synthetic 150-mer oligonucleotides (both microarray and sequencing data sets)[We obtained nucleosome prediction software from the authors' website _exe.html,23,24, aer models,29,31,32er models was obtaer models on all ser models, we predata sets), using data sets), which oDT performed the analyses. TRH coordinated the study. TRH and DT contributed to the preparation of the manuscript.Supplementary data and figures. Contains Table S1, and Figures S1-3.Click here for file"}
+{"text": "Superelectrophiles are multiply charged cationic species  which are characterized by their reactions with weak nucleophiles. These reactive intermediates may also undergo a wide variety of rearrangement-type reactions. Superelectrophilic rearrangements are often driven by charge\u2013charge repulsive effects, as these densely charged ions react so as to maximize the distances between charge centers. These rearrangements involve reaction steps similar to monocationic rearrangements, such as alkyl group shifts, Wagner\u2013Meerwein shifts, hydride shifts, ring opening reactions, and other skeletal rearrangements. This review will describe these types of superelectrophilic reactions. The Knorr cyclization is a classical method for preparing quinol-2-ones from \u03b2-ketoamides . In 19643CO+) salts in HF\u00b7BF3. These studies showed that acetyl cation (CH3CO+) salts were capable of abstracting hydride from the isoalkanes when the reactions were performed in superacdic media. Studies by Olah and coworkers had shown . In. In20) uation 25 . Protona28) was shown nona-3,7-diyl dication (88) was formed.A novel isomerization of a bicyclic ring system was described  for the 87 to 3.58 \u00c5 in 88.This isomerization is thought to occur through a series of hydride shifts, Wagner\u2013Meerwein shifts, ring contractions, and methyl shifts . Ab init90 from the disubstituted 1,4-cyclohexanediol  to methyl isopropyl ketone  is energetically unfavorable, presumably due to the closer proximity of the charges. In the final steps, the monocation 96 undergoes a hydride shift to form the carboxonium ion 97 which leads to ketone 98 on deprotonation. Methyl isopropyl ketone (98) is known . Th. Th122) 130 in HF-SbF5  in FSO3H and SO3 at \u221270 \u00b0C, followed by warming to 0 \u00b0C, gives a clean conversion to the protonated bicyclic lactone 140  shift and charge migration is inhibited.Several studies have examined this question using deuterium-labeled superelectrophiles. Reaction of 1-hydroxycyclohexanecarboxylic acid (tone 140  28]. A . A 137) 143 ionizes in superacid to give the 1,4-dication 144  shift, but rather via acid\u2013base chemistry. In this case, the acid\u2013base chemistry may be aided by the formation of a conjugated \u03c0-system in 145.In another study, the heterocyclic alcohol tion 144  45]. Fu. Fu143 i\u22121 stabilization. For example, the thiazole derivative 148 was reacted with CF3SO3H and then benzene to give two products  are increasingly important in stabilizing superelectrophiles as the ions become more densely charged or the charges are in closer proximity.Another recent study included calculations with the solution-phase model MPW1/6-311G(d)//PCMsp and the solvation was found to narrow the energy gap between a superelectrophile and its charge-separated species  45]. By. By45]. 155 reacts in superacid to give 5-methylbenzo[f]isoquinoline  are diprotonated and form the bis-oxonium ions, i.e., 160 as a stable species at \u221280 \u00b0C. When the solution is warmed to 25 \u00b0C, protonated acetaldehyde (162) is formed  (169. Both reactions are thought to involve hydride shifts.Olah and coworkers have described a series of reactions involving glycols and related substrates in superacids . These ss formed . The conol (165)  and for 172 in superacidic HF-SbF5 or HSO3F-SbF5 leads to formation of the 2-butenoyl cation (175, 174, which undergoes deprotonation to give the 2-butenoyl cation 176. Presumably, 174 is formed by rapid charge migration involving 173. Further evidence for the superelectrophile 174 is obtained from experiments in which the 2-butenoyl cation 175 is generated in DSO3F-SbF5. Significant deuterium incorporation is found at the \u03b1 and \u03b3 positions, suggesting equilibria involving 173\u2013176.Reaction of the 4-chlorobutanoyl cation ion 175,  47]. On. On172 iAs a result of their high charge densities, superelectrophiles can exhibit very high reactivities. Superelectrophilic reactivity extends beyond the realm of chemistry with weak nucleophiles. Superelectrophiles may undergo a variety of rearrangement reactions in order to form more stable structures or to lose positive charge. Typically, stabilized structures are characterized by greater separation of cationic charge centers. Superelectrophiles may also undergo structural rearrangements that lead to favorable deprotonation steps. This gives ions with reduced positive charge. Superelectrophiles have been shown to undergo ring opening reactions, alkyl group shifts, Wagner\u2013Meerwein shifts, and hydride shifts. Thus, superelectrophiles tend to rearrange by reaction steps similar to monocationic rearrangements."}
+{"text": "G protein coupled receptor kinase (GRK)-2 desensitizes and opposes \u03b2AR pro-contractile signaling by phosphorylating the receptor and inducing beta-arrestin (\u03b2arr) binding. We posited herein that GRK2 blockade might enhance the pro-contractile signaling of the \u03b22AR subtype in the heart. We tested the effects of cardiac-targeted GRK2 inhibition in vivo exclusively on \u03b22AR signaling under normal conditions and in heart failure (HF).\u03b21AR knockout (B1KO) mice with cardiac-specific transgenic mice expressing the \u03b2ARKct, a known GRK2 inhibitor, and studied the offspring under normal conditions and in post-myocardial infarction (MI). \u03b2ARKct expression in vivo proved essential for \u03b22AR-dependent contractile function, as \u03b22AR stimulation with isoproterenol fails to increase contractility in either healthy or post-MI B1KO mice and it only does so in the presence of \u03b2ARKct. The main underlying mechanism for this is blockade of the interaction of phosphodiesterase (PDE) type 4D with the cardiac \u03b22AR, which is normally mediated by the actions of GRK2 and \u03b2arrs on the receptor. The molecular \u201cbrake\u201d that PDE4D poses on \u03b22AR signaling to contractility stimulation is thus \u201creleased\u201d. Regarding the other beneficial functions of cardiac \u03b22AR, \u03b2ARKct increased overall survival of the post-MI B1KO mice progressing to HF, via a decrease in cardiac apoptosis and an increase in wound healing-associated inflammation early (at 24 hrs) post-MI. However, these effects disappear by 4 weeks post-MI, and, in their place, upregulation of the other major GRK in the heart, GRK5, is observed.We crossed \u03b22AR pro-contractile signaling and function. In addition, \u03b22AR anti-apoptotic signaling in post-MI HF is augmented by \u03b2ARKct, although this effect is short-lived.GRK2 inhibition in vivo with \u03b2ARKct is absolutely essential for cardiac \u03b2 For inshe heart . These diates it ,7. Addit2 and \u22125 . In contrylation ,7,12-16.actility ,15. By con in HF .2AR can switch its signaling from Gs protein-mediated to Gi/o protein-mediated, which is believed to underlie its anti-apoptotic effects and is a feature cardiac \u03b21ARs lack [2AR with the \u03b2arrs, which require prior receptor phosphorylation by GRKs, can have pleiotropic effects in cardiac myocytes, such as inhibition of apoptosis/promotion of survival by promoting extracellular signal-regulated kinase (ERK) signaling [2AR.On the other hand, cardiac \u03b2ARs lack -24. Finaignaling  and inhiignaling ,27, a crignaling -30. Thes1- and \u03b22ARs, i.e. terminating their G protein-mediated signaling through cAMP, it dramatically reduces cardiac inotropic and adrenergic reserves, and since it is markedly elevated in HF, its blockade represents an attractive therapeutic strategy for heart disease treatment [2AR in HF, and also that its action on \u03b22AR induces recruitment of \u03b2arrs with all their aforementioned myriad effects on this receptor\u2019s signaling, we hypothesized, in the present study, that cardiac GRK2 blockade in vivo might enhance \u03b22AR signaling post-MI. In order to study the effects of GRK2 blockade specifically on this subtype\u2019s signaling, without any interference by the qualitatively different \u03b21AR signaling, we utilized the \u03b21AR knockout (B1KO) mice [2AR to be capable of increasing contractility. In addition, \u03b22AR anti-apoptotic signaling post-MI is augmented by \u03b2ARKct, but only acutely.Cardiac GRK2 is a major negative regulator of \u03b2AR pro-contractile signaling -11. By dreatment -11,31-35KO) mice , which wKO) mice . After bWe developed the hybrid transgenic line \u03b2ARKct/B1KO by crossing the B1KO mice with the \u03b2ARKct transgenic mice, which express \u03b2ARKct only in cardiomyocytes. The \u03b2ARKct/B1KO\u2019s breed normally, without any gross abnormalities and present no overt cardiovascular or other phenotype (data not shown). Three-month-old male mice were chosen to undergo surgical MI in order to induce HF and were studied alongside age-matched male homozygous B1KO\u2019s (without \u03b2ARKct expression), which served as the control group.2AR stimulates contractility only very weakly, we first examined the cardiac function parameters of these mice, both in sham and post-MI groups. Echocardiography revealed that the B1KO mice display significantly decreased ejection fraction compared to control wild type (WT) mice, both under normal conditions (sham groups) and at 4 weeks post-MI, as expected since the \u03b21AR is the major \u03b2AR subtype in the heart stimulating contractility (Table\u00a0max LV pressure elevation parameter), even at the highest concentration of isoproterenol challenge  is the cardiac \u03b22AR capable of promoting contractility in response to agonist stimulation.Since GRK2 is a major (negative) regulator of cardiac \u03b2AR-dependent contractility in vivo, and the \u03b22AR-dependent contractiity, we examined the levels of PDE4D interaction with the \u03b22AR in cardiac membranes of these mice in vivo. As shown in Figures\u00a02AR with both the PDE4D3 and -D5 isoforms is significantly reduced in \u03b2ARKct/B1KO mouse hearts compared to control B1KO hearts, an effect that might enable \u03b2ARKct to enhance cardiac \u03b22AR-dependent pro-contractile signaling in vivo.To identify the main signaling mechanism underlying this dramatic effect of \u03b2ARKct on cardiac \u03b22AR signaling, anti-apoptosis/cardiac survival. Post-MI \u03b2ARKct/B1KO mice display markedly better survival post-MI compared to their B1KO counterparts  \u03b2ARKct, by blocking GRK2, reduces the uncoupling of \u03b22AR with the classical pro-contractile Gs protein-adenylyl cyclase-cAMP-PKA signaling pathway  , we also tested the effects of cardiac GRK2 blockade in vivo on this aspect of \u03b22AR signaling in the context of post-MI HF progression. We found that early on after MI, cardiac GRK2 blockade with \u03b2ARKct also dramatically augments \u03b22AR anti-apoptotic signaling, as well as its pro-infarct healing inflammatory signaling, in the heart. This results in significant reduction in all-cause mortality , and reduced cellular apoptosis in the post-MI heart, compared to B1KO mice with unopposed cardiac GRK2 activity. Thus, \u03b2ARKct enhances not only cardiac contractility, but also cardiac survival stimulated by the \u03b22AR, which further reinforces its validity as an attractive therapeutic strategy to potentiate cardiac \u03b22AR signaling and function in post-MI HF. Of course, enhancement of the anti-apoptotic signaling of other cardio-protective receptors that are also GRK2 substrates by \u03b2ARKct cannot be ruled out and is, in fact, quite likely to have contributed to the observed cardiac apoptosis phenotype of \u03b2ARKct/B1KO mice. However, \u03b2ARKct\u2019s cardio-protective and anti-apoptotic effects have been shown to be \u03b22AR-dependent, since selective blockade of this receptor in cardiac myocytes abolishes \u03b2ARKct-mediated anti-apoptotic effects [2AR-dependent pro-angiogenetic signaling, which plays an important role in peri-infarct HF progression [2AR contractile function without negatively affecting its anti-apoptotic one, but rather actually preserving and further enhancing this \u03b22AR function, as well.Since the other major beneficial effect of cardiac \u03b2 effects . On the gression , cannot 2AR pro-survival signaling; \u03b22AR can have remarkably different effects in the heart depending on its expression levels and on time [2AR is known to be beneficial  at low levels of overexpression and in the first few months of life in mice, but when overexpressed at extremely high levels in murine hearts or later on in the mouse\u2019s life, these animals do not survive and die of severe cardiac complications [2AR anti-apoptotic signaling is known to proceed mainly through the Gi/o protein signaling pathway [i/o proteins with the \u03b22AR, and b) by increasing the PKA-dependent switching of \u03b22AR signaling from Gs to Gi/o proteins thanks to the increase of \u03b22AR signaling via the Gs protein-cAMP-PKA (the pro-contractile) pathway it also causes, discussed above  early in life of transgenic mice or at low levels of receptor expression to detrimental (pro-apoptotic) later on in the lifespan of these mice or at very high levels of cardiac \u03b22AR overexpression [Meanwhile however, \u03b2ARKct also causes upregulation of the other major cardiac GRK, GRK5, in the first few weeks post-MI. This is also probably due to the enhanced NF\u03baB activation Figure\u00a0, since Npression . Of notepression . Therefo2AR subtype\u2019s pro-contractile function, all the while preserving and augmenting this receptor\u2019s beneficial anti-apoptotic/pro-survival and pro-infarct healing signaling pathways post-MI, early on after the cardiac insult. However, the effects of \u03b2ARKct on the latter signaling modalities are transient due (in part) to compensatory elevation of cardiac GRK5 over time.In summary, the present study reports that cardiac GRK2 inhibition with \u03b2ARKct in vivo is absolutely essential for the cardiac \u03b21AR KO (B1KO) (on C57/B6 background) [The animals in this study were handled according to animal welfare regulations and protocols approved by the authors\u2019 Institutional Review Boards. Genetically engineered, 8- to 12-wk-old \u03b2kground)  and the kground) , were uskground) .Transthoracic echocardiography was performed with a linear 30-MHz transducer , as described . In vivoHeart specimens were fixed with 10% neutral buffered formalin, embedded in paraffin, and sectioned at 5-\u03bcm thickness. DNA fragmentation was detected in situ in deparaffinized sections using the ApopTag Kit (Intergene) and according to manufacturer\u2019s instructions, as described previously . The tot3VO4, 10 mM NaF, 2.5 \u03bcg/ml aprotinin, and 2.5 \u03bcg/ml leupeptin. Protein concentration was then determined and equal amounts of protein per sample were loaded on SDS-PAGE gels for electrophoretic separation, as described previously [2AR-PDE4D co-immunoprecipitation experiments, \u03b22AR was immunoprecipitated with an anti-mouse \u03b22AR antibody , immobilized on Protein A-sepharose beads (Invitrogen), prior to SDS-PAGE/western blotting. Total I\u03baB\u03b1 and phospho-I\u03baB\u03b1 were detected by using anti-I\u03baB\u03b1  and anti-phosphoI\u03baB\u03b1 at Ser-32  antibodies, Bcl-2, GRK5, GRK2/\u03b2ARKct and GAPDH, with antibodies sc-492, sc-565, sc-562, and sc-25778, respectively , and PDE4D (various isoforms) with the PD4-401AP antibody (FabGennix). Immunoblots were revealed by enhanced chemiluminescence  and visualized in the FluorChem E Digital Darkroom (Cell Biosciences). Densitometry was performed with the AlphaView software (Cell Biosciences) in the linear range of signal detection (on non-saturated bands).Cardiac extracts were prepared in 20 mM Tris pH 7.4, 137 mM NaCl, 1% Nonidet P-40, 20% glycerol, 10 mM PMSF, 1 mM Naeviously . For \u03b22APro-inflammatory cytokines TNF\u03b1, IL-6 and IL-1\u03b2 were measured in serum obtained from left ventricular blood, immediately prior to heart excision and animal euthanizing, via multiplexed ELISA, as described ,48. The t test and one- or two-way ANOVA with Bonferroni test were generally performed for statistical comparisons, unless otherwise indicated. For all tests, a p value of <0.05 was generally considered to be significant.Data are generally expressed as mean \u00b1 SEM. Unpaired 2-tailed Student\u2019s 1AR knockout; GRK: G protein-coupled receptor kinase; \u03b2ARKct: Beta-adrenergic receptor kinase (GRK2) carboxyl terminal fragment; \u03b2arr: Beta-arrestin; PDE: Phosphodiesterase; MI: Myocardial infarction; HF: Heart failure; NF\u03baB: Nuclear factor-kappaB; I\u03baB\u03b1: Inhibitor of nuclear factor-kappaB alpha subunit; cAMP: 3\u2032-5\u2032 adenosine monophosphate (cyclic adenosine monophosphate); WT: Wild type; PKA: Protein kinase A; Gs: Stimulatory G protein; Gi/o: Inhibitory or other G protein; TNF\u03b1: Tumor necrosis factor alpha; IL: Interleukin; TUNEL: Terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling; Bcl-2: B-cell lymphoma 2; LV: Left ventricular; ELISA: Enzyme-linked immunosorbent assay.\u03b2AR: Beta-adrenergic receptor; B1KO: \u03b2The authors declare that they have no competing interests.NCS, XV, AS, GR, AC, DLic, CDL, and EG performed research. DLeos assisted with writing of the paper. WJK supervised the project, provided funding for the research and assisted with writing of the paper. AL conceived and supervised the project, designed research, provided funding for it, and wrote the paper. All authors have read and approved the final manuscript."}
+{"text": "P = 0.06). The occurrence of RAVs was associated with a resistant NS3 quasispecies phenotype (P<0.001), but the sensitivity of phenotypes was not associated with treatment outcome (P = 0.2). The majority of single viral and host predictors of SVR was only weakly associated with treatment response. In multivariate analyses, low AST levels, female sex and an IFNL4 CC genotype were independently associated with SVR. However, a combined analysis of negative predictors revealed a significantly lower overall number of negative predictors in patients with SVR in comparison to individuals with virologic failure (P<0.0001) and the presence of 2 or less negative predictors was indicative for SVR. These results demonstrate that most single baseline viral and host parameters have a weak influence on the response to triple therapy, whereas the overall number of negative predictors has a high predictive value for SVR.Triple therapy of chronic hepatitis C virus (HCV) infection with boceprevir (BOC) or telaprevir (TVR) leads to virologic failure in many patients which is often associated with the selection of resistance-associated variants (RAVs). These resistance profiles are of importance for the selection of potential rescue treatment options. In this study, we sequenced baseline NS3 RAVs population-based and investigated the sensitivity of NS3 phenotypes in an HCV replicon assay together with clinical factors for a prediction of treatment response in a cohort of 165 German and Swiss patients treated with a BOC or TVR-based triple therapy. Overall, the prevalence of baseline RAVs was low, although the frequency of RAVs was higher in patients with virologic failure compared to those who achieved a sustained virologic response (SVR) (7% versus 1%,  The first DAAs  targeting proteins with critical functions in the HCV replication cycle were the first-generation linear NS3 protease inhibitors (PIs) boceprevir (BOC) and telaprevir (TVR) . Both PIThe current new treatment standard uses IFN-free combinations of highly efficient DAAs that lead to very high SVR rates and are associated with few and mostly mild side effects. However, second generation protease inhibitors like simeprevir, paritaprevir or asunaprevir are frequently part of these therapies and overlapping resistance profiles with BOC-/TVR-associated RAVs may significantly impact rescue treatment options after failure of a BOC or TVR-based triple therapy . This stBetween 2012 and 2013 a German National non-invasive resistance study investigating baseline resistance  was performed at 16 study sites in Germany and one site in Switzerland. Inclusion criteria for the study were a chronic hepatitis C GT1 infection, a treatment-na\u00efve status or a pretreatment with (PEG)-IFN +/- RBV and a planned triple therapy with BOC or TVR. The exclusion criterion was an infection with GT2, 3, 4, 5 or 6. Caucasian patients were treated in a real-world setting with BOC or TVR in combination with PEG-IFN-\u03b1/RBV according to the label and serum and EDTA blood were collected from 196 patients before initiation of triple therapy. Epidemiological, biochemical, virological and histological parameters were documented. The outcome of triple therapy was classified as follows 1) SVR (negative HCV RNA 12 weeks after the end of treatment), 2) non-response , 3) non-response including breakthrough (achievement of negative HCV RNA followed by an HCV RNA increase of >1000 IU/mL or >1log10 during therapy), 4) relapse (achievement of negative HCV RNA at the end of treatment followed by positive HCV RNA post-treatment) . Patientxl Genetic Analyzer . Obtained sequences encompassing the 543 bp NS3 protease region (NS3 amino acids 1\u2013181) were proofread and aligned using BioEdit version 7.2.3 [in vivo and/or if they had been demonstrated to confer a greater than 2-fold change of susceptibility to BOC/TVR in comparison to a wildtype reference strain in vitro assays [HCV RNA extraction and amplification of the NS3 protease encoding region were done as previously described . Brieflyon 7.2.3 . RAVs weo assays . RAVs weo assays , 16, allFor the phenotyping of NS3 quasispecies variants, we used 33 patients with virologic failure available in July 2014 and randomly selected 51 patients with SVR out of a study population of 81 patients with SVR available at that time. Random selection used a randomization list calculated with the Matlab software package  and no significant differences were detected between the patients selected for phenotyping and the remaining individuals of the cohort. Including a patient number of 33 versus 51 individuals allowed a power above 85% to detect differences between the groups using a Wilcoxon-Mann-Whitney-U-test with a significance level of 5% if the Mann-Whitney estimator was at least 0.7.E. coli cells. Ten percent of the transformation mixture was plated onto LB-Agar with 100 \u03bcg/mL ampicillin to determine the ligation efficiency by comparison with a ligation reaction without insert. The remaining aliquot of cells was grown in LB medium containing ampicillin, followed by the plasmid isolation using the NucleoSpin Plasmid kit according to the manufacturer's protocol . Additionally, ligation was quality controlled by restriction digestion of the obtained library and by bulk sequencing to ensure the insertion of patient derived NS3 protease sequences. The parental pFKi341-PiLucNS3-3'_ET construct served as reference for GT1b patient samples. To generate a reference for GT1a patients, the NS3 protease from the H77 reference strain was amplified from pFKi341-PiLucH77S [For the construction of replicon libraries, the HCV GT 1b subgenomic replicon pFKi341-PiLucNS3-3'_ET  was modiiLucH77S  and insein vitro transcription as specified in 7 cells/mL in Cytomix [4 cells/well.Ten microgram plasmid DNA was linearized with PvuI, purified and used for  Cytomix  supplemeBOC and TVR were dissolved in DMSO and serially diluted to final concentrations of 0\u20133.3 \u03bcM; DMSO concentration was adjusted to 0.05% (v/v) in all concentrations. Four hours after electroporation, for each patient library an aliquot of the cells was harvested to determine the transfection efficiency by measuring the luciferase activity see  and BOC IL28B) using a StepOnePlus instrument  as described previously [Genomic DNA of patient samples was extracted from EDTA blood using the QIAamp DNA Blood Kit . A real-time polymerase chain reaction was conducted for SNP genotyping rs12979860  and 75\u03bcl of 1:4 diluted serum samples.IFNL4 non-CC genotype, HCV subtype 1a, a high HCV viral load, high IP10 levels, the presence of cirrhosis, the presence of BOC/TVR-associated RAVs, resistant phenotypes (>2-fold change). Based on results obtained in our cohort, cut-offs for the HCV viral load and IP10 levels were calculated. Therefore the median HCV viral load and IP10 level were calculated for the groups of patients with virologic failure versus SVR. A further calculation of the mean value using both medians resulted in a cut-off >1,971,750 IU/mL  and >428 pg/mL (IP10) which were used as negative predictors. Finally, for each patient the number of negative predictors present was analyzed.Adapted on previous studies , 24\u201328, IFNL4 genotype, HCV GT, cirrhosis, prior null response, NS3 RAVs) we applied contingency tables . A correlation of two parameters (fitness and IC50 fold change) was calculated using Spearman\u00b4s rank correlation. To analyze the influence of two factors on one parameter (e.g. cirrhosis and treatment outcome on phenotype sensitivity), a bifactorial rank analysis was conducted. To identify independent predictors of SVR, a multivariate logistic regression analysis was performed including all significant parameters from the univariate analysis and quantitative variables were transformed logarithmically. P-values of less than 0.05 were considered significant. For the investigation of different cut-off levels for the prediction of SVR, we performed a ROC analysis and used the Youden criterion for cut-off selection.Statistical analyses were conducted using BIAS . For the investigation of continuous variables , the Wilcoxon-Mann-Whitney-U-test (comparison of 2 groups) or the Kruskall-Wallis test (3 or more groups) were conducted. For an investigation of dichotomic variables (e.g. 6 IU/mL. The favorable IFNL4 CC genotype had 29% (n = 46) of patients. A liver cirrhosis was detected in 29% (n = 47) of individuals and 63% (n = 103) were treatment-experienced . The majority  was treated with a TVR-based triple therapy. The overall SVR rate of patients receiving a BOC or TVR-based triple therapy was 73% (n = 121). In separate analyses, the SVR rate for TVR-treated patients was 78% (n = 106) and for BOC-treated individuals 52% (n = 15).The baseline parameters of all 165 patients are displayed in P = 0.06).We investigated NS3 protease sequences at several positions which had been shown to be relevant for the emergence of RAVs. At baseline, RAVs were rarely detected. The most prevalent RAVs were T54S and V55A , followed by V36M  . T54S wain vitro in presence of the same PI also used in vivo. We found no correlation of the IC50 fold change value with the replication fitness of NS3 libraries (72h/4h ratio) . Similar to the prevalence of RAVs, the frequency of resistant phenotypes was low  and the occurrence of RAVs was associated with a resistant phenotype (P<0.001). Subgrouping of samples with virologic failure by relapse (Rel), breakthrough (BT) and non-response (NR) showed no differences compared to patients with SVR (P = 0.2). A slightly increased occurrence of resistant phenotypes was found in patients with subtype 1a, but no difference between samples from patients who failed antiviral therapy and patients with SVR was detected (P = 0.4).The sensitivity of the patient NS3 quasispecies towards BOC/TVR was investigated using a replicon based assay and IC50 values were calculated out of BOC/TVR titration curves as a measure for drug sensitivity . We conshenotype , P<0.001with SVR , P = 0.2detected , P = 0.4IFNL4 CC and CT genotypes compared to TT. However, phenotype sensitivity was not significantly associated with IFNL4 after subgrouping for the outcome of therapy . Interestingly, NS3 replicon libraries from patients with cirrhosis showed significantly lower IC50 fold change values in comparison to non-cirrhotic individuals (P = 0.02 each). The treatment history had no influence on the sensitivity of NS3 protease libraries (P = 0.3 each).Next, a possible influence of host factors on the sensitivity of viral phenotypes was investigated. We observed more resistant phenotypes in patients with IFNL4 CC genotype as remaining independent predictors of SVR (P<0.05). Among these, a low AST level was the factor with a high predictive value for SVR (P<0.0001).In univariate analyses several baseline parameters were significantly associated with SVR . In a muP<0.0001).We analyzed the number of negative predictors known from the literature see  in the sA ROC analysis identified the presence of 2 or less negative predictors as indicative for an SVR and 3 or more negative predictors were indicating a virologic failure . The PPVIFNL4 CC genotype. Viral parameters favoring SVR are a low baseline viral load and HCV genotypes 2 and 3 [For the success of a triple therapy with BOC/TVR, at least a partial response towards PEG-IFN/RBV is of central importance, as otherwise there is a risk of a functional PI monotherapy. Therefore, baseline factors that influence PEG-IFN/RBV response may also have an effect triple therapies with BOC or TVR . In the  2 and 3 , 24\u201326.The impact of baseline RAVs on the outcome of DAA-based therapies is discussed controversially. Before treatment initiation, NS3 RAVs are detectable at different frequencies; however RAVs are selected rapidly during PI treatment which may have the consequence of a viral breakthrough and treatment failure , 29, 30.Next, NS3 phenotypes were investigated in correlation with the outcome of triple therapy and other viral and host factors. For the generation of patient-derived NS3 libraries; LB medium was directly inoculated with the transformation mixture without prior selection of one clone which would represent only one NS3 sequence. Therefore, this approach enables to study the sensitivity of the NS3 quasispecies. As the fitness of NS3 replicon libraries correlated not with the BOC/TVR sensitivity, sensitive phenotypes are presumably not caused by a reduced replication fitness . The occIFNL4 genotype or the pretreatment status was found . This is probably due to an extremely high BMI of >45 which is associated with a potential underdosing of medication [As the majority of baseline predictors correlated only weakly with treatment outcome, the response to triple therapy may be influenced by a combination of several negative predictors. We investigated the prevalence of negative predictors described in the literature in the present cohort. Interestingly, the overall number of negative predictors was significantly lower in patients with SVR versus virologic failure and a cut-off of 2 or less negative predictors was indicative for an SVR . Also fodication .Nevertheless, another limitation of this study could be that PI-based triple therapies are not of major importance for the treatment of chronic hepatitis C anymore. However, some countries follow the policy that only patients who are difficult-to-treat are able to receive an IFN-free treatment. Individuals in an early stage of disease without any comorbidities should first wait or a PI-based triple therapy is offered to these patients. Moreover, the conduction of phenotypic analyses is also of importance for the investigation of resistance to all-oral HCV therapies. While pre-existing RAVs within NS3 are rare and especially the replication of high-level resistant variants is reduced, this is not the case for NS5A and non-nucleoside NS5B RAVs. Here, RAVs at baseline are frequently found without an impairment of viral replication. It is therefore reasonable that a phenotyping of the HCV quasispecies will be of more importance for patients treated with NS5A and non-nucleoside NS5B inhibitors.IFNL4 genotype, sex and AST levels turned out as independent predictors of SVR. Finally, the overall number of negative predictors was significantly lower in patients with SVR and the presence of 2 or less negative predictors was highly predictive for SVR.In conclusion our findings show a slightly higher prevalence of baseline RAVs in patients with virologic failure versus individuals with SVR, although this was not significant. Interestingly, the occurrence of RAVs correlated with a resistant NS3 phenotype in a replicon-based assay. Single baseline viral and host parameters were only weakly associated with the treatment response to triple therapy. In multivariate analyses S1 File(DOCX)Click here for additional data file."}
+{"text": "To date, several studies concerning the effects of induced abortion (IA) on women\u2019s later psychosocial well-being and future delivery complications have been published. However, the lack of reports on woman\u2019s physical well-being during their first full-term pregnancy occurring after IA is what inspired the current study. Here, we evaluate the physical well-being and use of maternity services of first-time mothers with a history of IA.Finnish National Birth Registry data from 2008 to 2010 were linked with the Induced Abortion Registry data from 1983 to 2007. After excluding first-time mothers with a history of miscarriage, ectopic pregnancy or delivery, 57,406 mothers were eligible for the study, with 5,167 (9.0\u00a0%) having experienced prior IA. Data from the pregnancy follow-up visits were evaluated and compared between IA mothers and primiparous mothers.2) than the control group mothers. A higher use of maternity health clinic (MHC) services, thrombosis prophylaxis and participation in a second trimester ultrasound and amniotic fluid sample testing were evident in IA mothers, whereas the likelihood of assisted fertilisation procedure(s) was elevated in the control group. A shorter interpregnancy interval (IPI) seemed to contribute to a late first MHC visit and first trimester serum screening test participation, a higher incidence of placenta samples and an increased presence of preeclampsia and maternal care for poor foetal growth.Women with IA had higher rates of smoking after the first trimester and were more likely to be overweight (body mass index >25\u00a0kg/mIA is associated with being overweight before the subsequent pregnancy and with smoking after the first trimester. More frequent pregnancy follow-up visits in the IA group may be due to greater participation in the placenta sample testing and use of thrombosis prophylaxis. No association between IA and preeclampsia, hypertension, gestational diabetes or preterm premature rupture of membranes was evident in the pregnancy parameters. According to our findings, experiencing IA decreased the need for fertilisation procedures before the next pregnancy when compared to primiparous mothers. Among the IA mothers, the short IPI seemed to contribute to the higher risk for preeclampsia and maternal care for poor foetal growth. However, more research is needed around the IPI before establishing its effect on later pregnancy. Induced abortion (IA) is something many women undergo at some point in their lives. According to World Health Organization\u2019s (WHO) statistics, 30\u00a0% of all pregnancies in Europe end in termination, with the highest and lowest sub-regional termination rates worldwide being in Eastern and Western Europe at 43\u00a0% and 12\u00a0%, respectively, per 1,000 fertile women [Various studies of the effects of IA on woman\u2019s well-being and later deliveries have been published. In Nordic countries with permissive legislation, society has a neutral attitude toward IA procedures and an effective maternity health care system \u2013 the psychosocial consequences of IA seem to be minimal \u20137. MaterN\u2009=\u20095,167) consisted of women becoming mothers for the first time with a history of IA. Women pregnant with their first child and with no prior pregnancy history were chosen for the non-termination group . Women with prior miscarriage, ectopic pregnancy or deliveries were excluded from the study. The data from MHC follow-up visits were attained from the National Birth Registry records, and all of the available follow-up parameters were examined between the two groups. For an unknown reason, the mothers\u2019 occupations were not recorded in the National Birth Registry records in 95.0\u00a0% of the cases of IA mothers  and 46.6\u00a0% of the cases of non-IA mothers . For this reason, we were forced to exclude occupational status from the background characteristics. Other parameters in the National Birth Registry data were routinely recorded, with no other high rates of missing data.The National Birth Registry records from 2008 to 2010 were used, in addition to the Registry for Induced Abortions from 1983 to 2007, to locate women becoming mothers for the first time in 2008\u20132010 to determine the groups for this study. The termination group , the tolerance test may be performed during pregnancy weeks 12\u201316 for the first time and again during pregnancy weeks 24\u201328 if needed.A blood glucose (BG) tolerance test was diagnosed as pathological if it had one of the following three values: at 0\u00a0h, BG \u22655.3\u00a0mmol/l; at 1\u00a0h, BG \u226510.0\u00a0mmol/l; at 2\u00a0h, BG \u22658.6\u00a0mmol/l. The tolerance test is generally performed at 24\u201328 pregnancy weeks, but if the risk for gestational diabetes mellitus (DM) is thought to be great  with Tukey\u2019s multiple comparisons adjustment. Additional multivariable model was used to assess confounding effects with certain background variables. All analyses were conducted with the SAS System for Windows version 9.4 .p\u2009<\u20090.0001), more likely to smoke after the first trimester of the on-going pregnancy (p\u2009<\u20090.0001) and less likely cohabiting (p\u2009<\u20090.0001) than the non-IA mothers (Table\u00a0p\u2009<\u20090.0001). Other than this, there were no significant differences in the background characteristics of the groups.The IA mothers were more often aged between 20 and 24\u00a0years or over 35\u00a0years p\u2009<\u20090.000, more lip\u2009=\u20090.0443) and hospitals  than non-IA mothers, with the overall pregnancy follow-up visits totalling up to 16.6 vs 16.2 visits (p\u2009<\u20090.0001), respectively. The IA mothers participated more often in the second trimester ultrasound screening  and the amniotic fluid sample testing , and they used thrombosis prophylaxis  more often during their pregnancy than did the non-IA mothers. Experiencing IA seemed to lessen the likelihood for assisted fertilisation procedure(s)  as well as participation in the first trimester serum screening test  when compared to the non-IA mothers. Pathological BG tests were more common in the IA group, but after adjusting for confounding factors, this difference disappeared. No statistical differences were evident between the groups in terms of hospital care during pregnancy, underuse of MHCs, chorionic villus sample procedures, bleeding, high blood pressure, prematurity, anaemia or antenatal corticosteroid use. After adjusting the analyses for age, cohabiting, smoking and weight, participation in the first trimester serum screening test was no longer significant. Interestingly, underutilisation of MHCs and participating in the BG tolerance test became statistically significant only after adjusting for confounding factors, suggesting that these two factors are more frequent among non-IA mothers than among IA mothers  in IA and non-IA mothers, respectively . Women with an IPI of 6\u201312 months were more often not cohabiting when compared to women with an IPI <6\u00a0months or and IPI >12\u00a0months . Weight was not statistically significantly different between the IPI groups, but smoking after the first trimester was clearly more common in IPI <12\u00a0months .Interpregnancy interval (IPI) categorisation revealed that among women younger than 25, the IPI was often shorter than in older women Table\u00a0. Only inTable\u00a0It seems that women with a history of IA have a tendency for a higher BMI and are therefore more commonly overweight before the following pregnancy than primiparous women are. Participation in the first trimester serum screening test was initially higher in IA mothers, but this difference disappeared after adjusting the analyses for confounding demographic factors. A higher rate of participation in the second trimester ultrasound screening was still evident after the adjustment, suggesting that perhaps the transition to parenthood becomes stronger in the second trimester of pregnancy. The amniotic fluid sample was taken more often in the IA group, possibly because the mothers in this group were more often over 35\u00a0years of age than the mothers in the control group. Thrombosis prophylaxis was more common in IA mothers than in non-IA mothers; this difference was evident even after adjusting the results for demographic factors. No studies suggesting this same association were found in the PubMed/MEDLINE search. This finding is challenging to explain, and the clinical significance of the finding may be minimal. Higher participation in amniotic fluid sample testing and use of thrombosis prophylaxis may have contributed to the higher number of MHC and hospital check-ups in the IA group. Underutilisation of MHC services was more evident in the non-IA group than in the IA group, suggesting that perhaps mothers with prior IA are psychologically more aware of their pregnancy and want to ensure the best possible follow-up for their future offspring.Fertilisation procedures were reported more often in the primiparous group, indicating that infertility after an IA is not a common problem, which supports review by Lowit et al. . GestatiShort IPI (<12\u00a0months) was more common in young mothers, mothers living alone and those who continued to smoke after the first trimester of the on-going pregnancy. Even though we were unable to evaluate the educational level or occupation of the mothers due to poor documentation, these findings of age, habitation and smoking are generally considered to be partial indicators of a low socioeconomic status. Late first visits to MHC services are most common in mothers with IPI\u2009=\u20096\u201312 months when compared to mothers with IPI <6\u00a0months or IPI >12\u00a0months. This may contribute to the results of mothers with IPI >6\u00a0months participating more often in the first trimester serum screening test than mothers with shorter IPIs, possibly because they have missed the time window for the screening test. More frequent participation in the placenta sample testing in mothers with IPI \u226412\u00a0months might be explained by the late first visit and missing the first trimester serum screening test. Therefore, if anything pathological is suspected in the first trimester ultrasound screening test, these mothers are guided to the placenta sample test/amniotic fluid sample test. Presence of preeclampsia among IA mothers did not differ from the non-IA mothers in this study. However, in IA mothers, preeclampsia was more common the shorter the IPI was.. This all contributes to the higher number of hospital and total follow-up visits in mothers with shorter IPIs compared to mothers with longer IPIs. Also, maternal care for known or suspected poor foetal growth was more common IPI\u2009=\u20096\u201312 months than shorter or longer IPIs. After evaluating the literature \u201323, we s2, with approximately 35\u00a0% of the mothers being overweight. In addition, 15.3\u00a0% of all parturients smoked during pregnancy, with 46\u00a0% of these women stopping smoking during pregnancy. A study conducted from 1989 to 2001 [According to the 2014 perinatal statistics issued by the National Institute for Health and Welfare , the mea to 2001  examinedThe strengths of this study are its reliance on the registry-based parameters of the participants and the fact that we were allowed to combine the National Birth Registry records of all of Finland in the years 2008\u20132010 with the records from the Induced Abortion Registry in order to determine the absolute value of different parameters examined here. No participants were contacted and no questionnaires were completed, thus excluding personal feelings (positive or negative) concerning IA or maternity health care visits. In addition, we felt that all of the participants were in an equal position regarding MHC follow-up, as none of the mothers had prior deliveries and had therefore not attended MHC follow-ups before. In addition, we could assume that, as first-time mothers, there was no stress of prior offspring contributing to these pregnancy follow-up parameters. It would have been interesting to report the symptoms or feelings the mothers themselves may have experienced during their pregnancy in addition to these registry-based facts.We conclude that in pregnancy follow-up parameters, there are no significant risks evident regarding the upcoming delivery. Prior findings on IAs\u2019 association with preterm birth \u201312 were After examining the data of the first-time mothers covering all of Finland in the years 2008\u20132010, we suggest that IA may be associated with overweight before the next pregnancy and smoking after the first trimester of the on-going pregnancy. IA mothers tend to use MHC services slightly more than non-IA mothers. No association between induced abortion and preeclampsia, hypertension, gestational diabetes or preterm premature rupture of membranes was evident in our study. Short IPI seems to contribute to late first visits to MHCs, adding extra screening procedures to the pregnancy follow-up and burdening the otherwise well-functioning MHC services. Furthermore, our findings suggest that foetal growth and preeclampsia need to be monitored carefully with first-time mothers with short IPIs\u00a0after IA, although more thorough research in this subject is needed. Already when performing the IA, it could be beneficial to inform the women about the importance of adequate MHC visits in the possible following pregnancy. In addition to the adverse effects of the IA, it is reassuring to find positive outcomes of the procedure, that is, that IA is protective against secondary infertility."}
+{"text": "Orbital involvement in systemic sarcoidosis is a rare condition. We report a case of orbital sarcoidosis with bilaterally huge lacrimal gland involvement as the initial manifestation of systemic sarcoidosis. A 20-year-old woman admitted the ophthalmology department with progressive bilateral upper eyelid swelling for 6 months. The only pathologic finding was the presence of bilateral, symmetrical, solid, lobular masses at the lateral upper eyelids at the location of lacrimal glands. On systemic examination, bilateral parotid and submandibular glands appeared swollen. Magnetic resonance imaging of the orbit revealed bilateral symmetrical diffuse enlargement of the lacrimal glands with maximum and minimum thickness of 11 mm and 7 mm, respectively. The biopsy findings were compatible with sarcoidosis. Although lacrimal gland involvement has been reported in different studies, we for the first time report an unusual case with bilateral diffuse huge lacrimal gland involvement. Normal lacrimal gland thickness is approximately 4-5 mm in magnetic resonance imaging, while our case had bilateral diffuse enlargement of lacrimal glands, which showed maximum and minimum thickness of 11 mm and 7 mm, respectively. Although orbital involvement is uncommon in sarcoidosis, it should be remembered in the differential diagnosis of orbital masses. Lacrimal gland involvement is the most common form of orbital sarcoidosis.3 We present a case of orbital sarcoidosis with bilateral enlargement of the lacrimal glands with eyelid and anterior orbital involvement as the initial manifestation of systemic sarcoidosis.Sarcoidosis is an idiopathic, multisystem disorder that can affect any organ system and is mainly characterised by pulmonary, dermatologic, and ocular involvement. Its pathological hallmark is non-caseating granulomatous inflammation. Ocular involvement has been reported by different studies at a rate of 25-60%.A 20-year-old woman was admitted to the ophthalmology department with progressive bilateral upper eyelid swelling for 6 months. She had no other symptoms related to her eyes. A physical examination revealed dry mouth and nasal congestion. She had a history of triamcinolone (Nasacort) nasal spray usage for nasal congestion for nine months. Her family history was unremarkable. Her best corrected visual acuity was 10/10 in both eyes. The only pathologic finding identified through slit-lamp biomicroscopy was the presence of bilateral, symmetrical, solid, lobular masses in the lateral upper eyelids at the location of the lacrimal glands . There wSkin examination revealed subcutaneous nodules in the scalp. Upon systemic examination, the bilateral parotid and submandibular glands appeared swollen . MagnetiThe patient was referred to the chest disease department for pulmonary involvement. Laboratory examination showed an elevated angiotensin converting enzyme level of 63 U/L. Blood and urine calcium levels were within normal limits. The tuberculin skin test result was anergic. A chest x-ray demonstrated bilateral hilar enlargement. A thoracic computer tomography revealed bilateral hilar, subcarinal, and aortopulmonary lymphadenopathies as well as perilymphatic and peribronchovascular nodules in both lungs. Pulmonary function test results  were normal. No treatment was recommended for the pulmonary involvement.st day of treatment the steroid dose was reduced to 4 mg/2 weeks. The patient was treated with tapered dose steroids for nine months, and no relapse was observed at the first year follow-up -related Mikulicz\u2019s disease are the main pathologies that should be considered in the differential diagnosis of sarcoidosis. Although these diseases can be seen at any age, Sj\u00f6gren\u2019s syndrome and tuberculosis are the primary diseases for the differential diagnosis of sarcoidosis in younger patients. These diseases can cause bilateral involvement and are usually characterised by painless enlargement of lacrimal glands for more than one month. Although clinical findings and imaging tests can help guide clinicians, a biopsy is required for all patients with orbital masses of unknown origin.7The characteristic histological feature of sarcoidosis is non-caseating granulomas consisting of epithelioid histiocytes and lymphocytes. Multinucleated giant cells are frequently seen. Although tuberculosis is also characterised by chronic granulomatous inflammation, in tuberculosis the granulomas tend to be coalescent with necrosis. The presence of atypical lymphocytes in lymphoma, IgG4-positive plasma cells in IgG4-related Mikulicz\u2019s disease, periductal and perivascular inflammation of lymphocytes and intralobular fibrosis in Sj\u00f6gren\u2019s syndrome are the main factors that aid in the differential diagnosis of sarcoidosis.8 whereas our case had bilateral diffuse enlargement of the lacrimal glands, which possessed maximum and minimum thicknesses of 11 mm and 7 mm, respectively.This case is important because the first symptom of systemic sarcoidosis in this case was diffuse enlargement of the lacrimal glands with eyelid and anterior orbital involvement. MRI reveals normal lacrimal gland thickness to be approximately 4-5 mm,Although orbital involvement is uncommon in sarcoidosis, it should be considered in the differential diagnosis of orbital masses. This case is striking compared to the previous case reports in the literature with respect to bilateral and substantially larger lacrimal gland involvement. The diagnosis of sarcoidosis should be made by clinical, laboratory, and radiological findings and confirmed by histopathological examination. It is necessary to screen all systems, and treatment decisions should be based on the presence of the organ and system involvement."}
+{"text": "The prognostic value of epidermal growth factor receptor (EGFR) mutations and the correlation between EGFR mutations and the new International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) histological classification remain controversial. The current study aimed to investigate the pure prognostic role of EGFR mutations in treatment-na\u00efve patients with resected stage I lung adenocarcinoma.We retrospectively reviewed 373 patients with stage I pulmonary non-small-cell lung cancer who underwent complete surgical resection between January 2010 and May 2014. The tumors were classified according to IASLC/ATS/ERS criteria. EGFR mutation status was determined by established methods.A total of 120 patients were included for analysis; 87 had tumors with EGFR mutations and 33 had wild-type tumors. More low- and intermediate-grade tumors had EGFR mutations, and nearly half of the high-grade tumors were wild-type . Patients with low-grade tumors had significantly greater median disease-free survival (DFS)  and better overall survival (OS)  than those with intermediate- and high-grade tumors. Tumor recurrence was 41.4% and 30.3% in mutant and wild-type patients. The 5-years survival rate was 54% and 71.2%. Multivariate analysis revealed that the new histological classification and the pathologic stage were independent predictors of both DFS and OS. EGFR mutation status had no prognostic implications.Low grade tumors according to IASLC/ATS/ERS histological classification and the pathologic stage IA tumors of resected stage I lung adenocarcinomas independently predict better DFS and OS. EGFR mutations were frequently seen in histologically low- and intermediate-grade tumors but not a prognostic factor. Lung cancer is the major cause of cancer-related death worldwide . CompletUnlike the predictive role of gene mutation in EGFR-TKI therapy, the prognostic value of EGFR mutation status has remained controversial, with conflicting results until now \u201322. The Considering the potential interference of perioperative therapy, the current study focuses on the pure prognostic impact of EGFR mutations in patients with resected stage I lung adenocarcinoma. We also investigate correlations between IASLC/ATS/ERS histological classification and EGFR mutation status .This retrospective study was approved by our institutional review board (201700457B0). The tissue specimens for genetic analysis were obtained with the patients\u2019 consent. Between January 2010 and May 2014, a total of 373 patients with stage I pulmonary NSCLC underwent complete surgical resection at Linkou Chang Gung Memorial Hospital. Among them, 186 patients were tested for EGFR mutation status at the same time as routine pathologic review of the resected specimen. We excluded patients with stage II, III, or IV NSCLC; those who had positive surgical margins, tumor histological findings other than adenocarcinoma, or absent or failed EGFR genotyping; and those who received neoadjuvant or adjuvant therapy. The final cohort consisted of 120 patients.The resected specimens were formalin-fixed and stained with hematoxylin and eosin in the conventional manner. Each tumor was reviewed using comprehensive histological subtyping by semiquantitatively estimating the percentages of the various subtypes present in 5% increments according to the IASLC/ATS/ERS classification . The preData on baseline patient characteristics were collected, including age, sex, smoking history, and Eastern Cooperative Oncology Group (ECOG) performance status. The date and type of surgery were recorded. Tumor stage was categorized according to the seventh edition of the American Joint Committee on Cancer guidelines for NSCLC . After tThe patients were divided into two groups, EGFR mutant and wild-type, based on the presence or absence of EGFR. Associations between clinical characteristics and recurrence rates were examined by Fisher\u2019s exact test. DFS and OS were analyzed by the Kaplan\u2014Meier method, and survival curves were compared by the log rank test. Independent prognostic factors for DFS and OS were determined by Cox multivariate analysis. Statistical significance was set at p < 0.05. The statistical analyses were performed with GraphPad Prism statistical software, version 6  and IBM SPSS Statistics 20 for Mac .The characteristics of the 120 patients and their tumors are summarized in Among the EGFR mutant group, 84 patients had a single mutation and 3 patients had double mutations. The most frequent EGFR mutations were the exon 21 point mutation L858R in 52 patients (59.8%) and the exon 19 deletion in 31 patients (35.6%). All of the three patients with double mutations had L858R. One of these patients had the exon 20 mutation T790M, one had R776H, and one had the exon 21 mutation K806I. The remaining four patients had rare mutations, including one patient with exon 20 insertion mutation, one with exon 20 deletion, one with exon 18 G724S, and one with exon 18 G719X.The median follow-up time was 46.7 months. Tumor recurrence was observed in 46 patients . Four patients died of non-lung-cancer-related disease without tumor recurrence (two in the EGFR mutant group and two in the wild-type group). The median DFS was 76.8 months in the EGFR mutant group and was not reached in the wild-type group (p = 0.39) , Table 2Treatment after disease recurrence is summarized in There were 16 deaths, 13 in the EGFR mutant group and 3 in the wild-type group (p = 0.55). The median OS was unreached in both groups, and OS was comparable between groups . The estimated 5-year survival rate was 78% in the EGFR mutant group and 96.8% in the wild-type group  p = 0.4. The proTo our knowledge, this is the first study to focus on the prognostic difference by EGFR genotype and IASLC/ATS/ERS histological classification in resected stage I pulmonary adenocarcinoma. We investigated the outcomes in a cohort of 120 patients who had known EGFR mutation status and no perioperative therapy. We found that EGFR mutation status was unrelated to DFS and OS. EGFR mutations were more frequent in patients with low- and intermediate-grade tumors. Pathologic stage and IASLC/ATS/ERS histological classification were independent prognostic factors for both DFS and OS in patients with resected stage I pulmonary adenocarcinoma.There is accumulating evidence for a prognostic role of EGFR gene mutations in patients with resected NSCLC , 29, 30.Izar et al. found that patients with resected stage I, EGFR mutation-positive NSCLC without adjuvant therapy had significantly better DFS and OS than those with wild-type tumors . Only 62Kobayashi et al. showed that tumor differentiation was the only independent factor for unfavorable OS and DFS . They alAccumulating evidence has validated the prognostic significance of the predominant histological subtype based on the IASLC/ATS/ERS classification rather than gene mutation status , 36\u201338. Our study has several inherent limitations. First, it was retrospective in design and conducted in a single center. There were 187 excluded patients who were not genotyped. Sixty-six patients were excluded because they had received perioperative treatment. Thus, the proportion of EGFR mutant tumors is somewhat higher in our study compared with general population in lung cancer patients. Second, the rule of EGFR mutation detection methods in our hospital is based on the tumor purity. Because the sensitivity of detection methods is different, this may somewhat interfere the outcome. Third, we only analyzed the outcome of patients with tumors harboring EGFR mutations and the relationship between EGFR mutations and histology. Because of the rarity of KRAS mutations in Taiwan, we did not investigate the potential influence of these mutations.In summary, our study demonstrated that patients with stage IA tumor and those with low-grade tumors had better DFS and OS in patients with resected stage I lung adenocarcinoma who had no perioperative therapy. Although EGFR mutations were more frequently seen in patients with low- and intermediate-grade tumors, they had no prognostic implication. To investigate the prognostic role of driver mutations in lung adenocarcinomas and analyze the molecular correlations with histological subtypes, further prospective studies are warranted of larger numbers of patients, focusing on early-stage, resected lung cancer without perioperative treatment.S1 Dataset(XLSX)Click here for additional data file."}
+{"text": "This study was conducted to assess outcomes in patients with hydrocephalus who underwent ventriculoperitoneal shunting at Keen\u2019s point.This retrospective study was conducted in Combined Military Hospital (CMH) Peshawar. Time frame was four years from January 2011 to January 2015. The presenting complaints, clinical findings, investigations, treatment plans and surgical outcomes were noted. Ventriculo-Peritoneal (VP) shunting was done at Keen\u2019s point. The presence of shunt complications in the first week post-surgery was noted and at a three-month follow up in the outpatient department. General condition of the patient, shunt complications, presence of seizure and worsening of vision were noted.Study included 143 patients, out of whom 46 were females and 95 were male patients. Most common causes of hydrocephalus were congenital (79). Majority of adults had hydrocephalus due to central nervous system tumors while congenital hydrocephalus in children was most frequently due to aqueductal stenosis. Good clinical improvement was seen in 114 patients after shunt placement, satisfactory in 20 patients, 7 patients died while we observed no change in two patients.Our experience with VP shunting at Keen\u2019s point resulted in excellent outcomes. It can be used for the management of hydrocephalus both in pediatric as well as adult population. Hydrocephalus is defined as a condition in which there is abnormal accumulation of cerebrospinal fluid in the ventricles of the brain. It is mostly associated with an increase in the Intracranial Pressure (ICP).The main surgical strategy to manage this problem is the placement of Ventriculoperitoneal (VP) shunt. VP shunt insertion is the most common procedure done in neurosurgery and also remains the gold standard surgical procedure to manage Hydrocephalus (HCP).4VP shunt is a CSF diversion device, basically a tube, having a pressure-regulating valve that carries CSF from the ventricular system to another absorptive surface outside the brain such as the peritoneum. However it has very high failure rate, which is almost 40% to 50% for pediatric patients and 30% for adults.8Complications of shunts include shunt malfunction, shunt failure, and shunt infection along with infection of shunt tract. Malfunction is the most frequent cause of shunt revision.10VP shunting involves identification of external landmarks to help in determining the shunt\u2019s entry point. Different locations are used for placing the catheter of the shunt. These may be occipital (Frazier\u2019s point or Dandy\u2019s point), parietal (Keen\u2019s point) or the frontal (Kocher\u2019s point). Keen\u2019s point at the parietal side is almost 2.5-3 cm posterior and superior to the pinna while the direction and length of shunt insertion is almost 4-5 cm perpendicular to the cortex. Insertion of VP shunt is preferred at parietooccipital area because the frontal lobe has much lower seizure threshold than the occipital or parietal lobe and hence may lead to post-operative seizures. The distance between parietooccipital area and peritoneal cavity is also shorter which avoids the need of an additional incision.11We tried to evaluate the success of VP shunting at Keen\u2019s point in our peripheral neurosurgical setups. The result may help in defining the standard protocols for managing hydrocephalus in developing and underdeveloped countries.A retrospective study of all cases operated at our center over a period of four years from January 2011 to January 2015 was carried out. The study took place at Combined Military Hospitals at Quetta and Peshawar, from 2011-2012 and 2012-2015 respectively. All the patients, who presented, were investigated and operated for hydrocephalus with primary VP shunting were enrolled in this study. Patients were not considered for an Endoscopic Third Ventriculostomy (ETV) because of non-availability of this facility. An informed consent was obtained from all the patients or their guardians and demographic data was noted. The presenting complaints, clinical findings, details of investigations, details of treatment, along with the surgical outcome of patients were noted. All the data was collected in Microsoft Excel and later analyzed using SPSS 21 software.nd generation cephalosporins. Three doses of antibiotics were given.Base line investigations were carried out for every patient, which included Full Blood Count (FBC), Liver Function Tests (LFTs), Renal Function Tests (RFTs), screening for hepatitis B, hepatitis C and HIV and serum electrolytes. MRI brain was carried for diagnosis of hydrocephalus. Pre-operative antibiotic prophylaxis was done with 2All the patients had the VP shunt inserted at Keen\u2019s point. Parieto-occipital area was shaved and the skin was cleaned from head to below the umbilicus. Drapes were applied, while Keen\u2019s point as well as an abdominal site for peritoneal access was marked with a sterile needle. The patient was placed in supine position with the head turned 90 degrees to the opposite side of shunt placement. We used medium gradient Chhabra shunt in all patients below 15 years of age. This shunt was preferred relative to other available shunts because of unique spring system of the shunt due to which it is housed in the subcutaneous tissue of the neck. The skin in the infants and children is fragile and necrosis can occur with other shunts but since Chhabra shunt is mainly retained in the subcutaneous tissue of the upper neck, it rarely causes necrosis of the skin. These findings were observed by the operating surgeon. After verifying the shunt system for patency, a small semilunar scalp flap was raised at Keen\u2019s point in a way that the point was at the center of the flap. A small retractor was placed in the incision in order to expose the skull while a small burr hole was made with a scalpel to expose the dura.A small incision was made in abdomen, almost 2 cm superior and lateral to the umbilicus and carried down to the level of anterior layer of rectus sheath. A shunt passer was then tunneled subcutaneously from the abdominal incision to head incision. Distal aspect of shunt system was then passed through the shunt passer, avoiding its contact with the exposed skin. The shunt passer was later on withdrawn from the patient and after incising the dura with a size 11 blade, the ventricular catheter was introduced into the ventricles and connected to the rest of the shunt system using the connector. The ventricular catheter was then sutured to the pericranium with silk 3/0.Moving back to the abdominal incision, the anterior layer of the rectus sheath was incised, as the muscle was dissected and peritoneum opened. The abdominal catheter was inserted into peritoneal cavity and cavity was closed by vicryl 3/0. The abdominal skin and scalp were closed with nylon 3/0.The presence of shunt complications in the first week post-surgery was noted. The clinical outcome of each patient was assessed at a three-month follow up in the outpatient department. General condition of patient, vomiting, bulging of fontanella, shunt complications, presence of seizures, fronto-occipito cranial diameter, excessive crying of child, feeding status were the parameters noted on the follow-up in children.We included a total of 143 patients, out of whom 46 were females while 95 were male patients. There were no drop outs from the study. The mean age was 21.56 years with a standard deviation of 23.50 years.Right sided VP shunting was performed in 114 (78.6%) patients while 31 (21.4%) had left sided shunting. Recommended site is right sided approach but in some of the patients due to presence of tumors, adhesions and injuries from previous trauma on right side, left sided approach was done. The causes of Increased Intracranial Pressure in our subjects (N=145) are shown in Vomiting, bulging of fontanelle, frontooccipitocranial diameter, excessive crying of child, feeding status were the parameters noted on the follow-up in children. In three months follow up, good clinical improvement was seen in 114 (78.6%) patients, satisfactory in 20 patients while no change was observed in based on the above parameters. Seven (2.5%) patients died while we observed no change in two (1.9%) patients. Various complications noted are given in One of the complications noted was the intracranial migration of ventricular catheter in a child of three years of age. This patient also developed meningitis. Patient was re-operated and catheter was removed. All cases of shunt malfunctions were found in infants of less than 10 months of age. Seizures were noted in two infants of ages nine months and one year. Infections were noted in three patients of ages one year, 16 months and 18 months.Our study was carried out at general neurosurgical unit of tertiary care facility of Khyber Pakhtunkhwa province of Pakistan. As there are only a few units for neurosurgery in the province, hence we had patients from all areas of the provinces.The number of male patients in our study was more compared to female patients, which is consistent with other studies carried out around the globe.We achieved good results in 79.47% of the patients. All the patients, in whom no change was observed even after treatment, had post-traumatic communicating hydrocephalus. Patients who are managed with VP shunts must be periodically evaluated to check for any complication. The complication rate of the VP shunt surgery ranges around 30% to 40%, with some studies having failure rate up to 46%15Headache is the common presenting symptom, while visual deterioration is the most serious consequence of increased intracranial pressure. Patients undergo CSF diversion procedures like VP shunting to lower the increased intracranial pressure and protect vision.Previous studies state hemorrhage to have the most detrimental effect on the shunt functioning.Development of hydrocephalus following cranial surgery may be attributed to the damage that occurred to cells of the choroid plexus and other nearby tissues during the surgical procedure21The high success rate proves that VP shunting at Keen\u2019s point to treat hydrocephalus, can be carried out at peripheral setups even in developing countries. We recommend this treatment in all setups where the latest equipment is not available.In our experience, the results of VP shunting at Keen\u2019s point proved to be a successful procedure even at peripheral neurosurgical centers, with the non-availability of ETV. Therefore it can be used for the management of hydrocephalus, both in pediatric as well as adult population. High rates of failure are mentioned in some studiesMJ: Contribution to conception, design and acquisition of data.MA: Analysis and interpretation of data, drafting the manuscript.MUR: Conception and design, revision of manuscript"}
+{"text": "Surveys among adolescents were held to obtain contextual information about the schools. Four focus group discussions and fourteen individual interviews were held with adolescents to identify shared smoking patterns in each school. Two shared patterns were identified at a school where 17% of students smoked daily: Dependent smoking and Rebellious smoking. Both built on pro-smoking norms and underscored the benefits of smoking. Three shared patterns were identified at a school where 3% of students smoked daily: Social bonding smoking, Low-profile smoking and Smoking-friendly event smoking. These built on anti-smoking norms and helped smokers cope with negative social judgements related to smoking. We conclude that adolescent smoking during school hours is embedded in diverse shared smoking patterns. Future studies should develop more understanding about how to deal with adolescents\u2019 shared smoking patterns that decrease the effectiveness of tobacco policies.Large numbers of adolescents smoke during school hours, despite the implementation of smoke-free school policies (SFSPs). Studies about SFSPs predominantly analyse smoking as individual behaviour, yet there is increasing recognition that smoking should be understood as social behaviour. We explored shared smoking patterns specifying  Policy makers in many European countries have adopted legislation that compels secondary schools to implement smoke-free school policies (SFSPs). The aim of SFSPs is to limit tobacco use by defining who is prohibited to smoke where and when, and prescribing what consequences will follow when rules are violated. Political support for SFSPs can be explained by evidence about the high proportion of smokers that have taken up smoking during adolescence , the infContemporary studies assessing the impact of SFSPs on adolescent smoking behaviour present largely inconsistent results . A key rBuilding on these implications, a recently published literature review identifies adolescents\u2019 cognitive and behavioural responses to the implementation of SFSPs . One keywhere, when, and with whom, and social meanings about why they smoke during school hours. These shared smoking patterns may contribute to adolescents smoking persisting during school hours by allowing smokers to collectively adapt their smoking to deal with stronger SFSPs and by attracting non-smokers to follow similar patterns. \u201d (HFD).Boys and girls smoked together in an indistinct group that also included non-smokers. They stood either alone, with their friends or with anyone who is having a smoke. Smoking during school hours was widely accepted; most adolescents did not judge smokers as those against smoking were clearly framed as the minority.\u201cI don\u2019t think so because there are many smokers (\u2026) The only ones who really are against smokers are those \u2018real anti-smokers\u2019\u201d (HF1).The widespread acceptance of smoking related to adolescents\u2019 perceptions that everyone could be a smoker and that there are sensible external reasons that could cause someone to start smoking and so become nicotine dependent.Boy1: \u201cWhen I joined this school I noticed right away that there is a lot of smoking\u201d.Boy2: \u201cI think about a quarter of the school\u201d.Boy1: \u201cMaybe even half\u201d.Boy3: \u201cEven those individuals you don\u2019t expect\u201d.Boy1: \u201cYes, these correct types.\u201d (HMD).One reason they gave for starting smoking was that it reduces stress. This stress was oftentimes associated to the school setting or the home environment. Another reason was group pressure. The group pressure at school was quite strong, as some adolescents stated that they need to actively prevent themselves from giving in to this group pressure.\u201cI protect myself by not standing there [near smokers] (\u2026) I\u2019m afraid that they will ask me [to smoke] and I\u2019m not the type of person that easily says no\u201d (HMD).need to smoke during school hours should not be withheld from the opportunity to smoke a cigarette.The decision to start smoking was nevertheless generally seen as an individual choice because someone always has the option to say no. Both smokers and non-smokers therefore argued that adolescents who Girl1: \u201cIt is their own life and if they want to smoke because they really need it, then it should be possible\u201d (HFD).Where: outside the school premises;When: every school break;With whom: single-gender friend groups;Why : expresses toughness.A minority of smokers smoked during school breaks at locations just outside the school premises, predominantly behind a bus station with an adjacent bench. These adolescents smoked in single-gender friend groups that consisted only of smokers. They smoked outside the premises because it allowed them to meet with adolescents from other schools and it gave them privacy from teachers\u2019 supervision.\u201cPeople from other schools come to us, but they\u2019re not allowed to enter the school premises, so we stand there [behind a bus station]\u201d (HF2).Boys who smoked near the bus station described the girls smoking there as \u201cfeeling unashamed\u201d and \u201cstanding with their legs far apart [non-feminine]\u201d (HM1) and framed smokers outside the premises as \u201ctougher\u201d than the others. They underscored this toughness by talking about their minor violations of the smoking rules that teachers did not sanction.\u201cRules exist to be broken (\u2026) I light a cigarette and when the bell rings and I\u2019m not finished yet, then I walk over the [smoke-free] school premises with my cigarette\u201d (HM1).Other adolescents, including those who smoked only in the official smoking area, judged harshly about the boys and girls smoking outside the school premises. Individuals were described as offensive and it was generally believed that they try to \u201cact tough in front of teachers\u201d (HF3).Boy1: \u201cSimply these unmannered children\u201d.Boy2: \u201cThose of the street\u201d.Boy3: \u201cScum\u201d.Boy2: \u201cYes, street scum\u201d (HMD).These perceptions made most smokers decide not to smoke outside the school premises, reasoning that these smokers are different and do not want to be associated with them.\u201cNo, I don\u2019t smoke there. There\u2019s always these people. The tougher people\u201d (HF4).Lowsmoke was a school with 750 adolescents that provided full-time mid-level education. The survey showed that 29% of 3rd and 4th graders ever smoked and 3% smoked daily. Also, 52% were girls and 27% were exposed to at least one smoking parent.the gate. Smokers were only allowed to smoke at this area because Lowsmoke did not want smoking to be comfortable; there was no bench to sit or roof to shelter for rain. There was a parking lot between the gate and the school premises, physically separating smokers from non-smokers. Lowsmoke only allowed the 3rd and 4th graders to leave school premises during school hours, including free time between teaching hours that occurred due to gaps in adolescents\u2019 timetables. This technically meant that only 3rd graders onwards were allowed to smoke during breaks and free-hours.Lowsmoke prohibited smoking in the school buildings and on its premises. The only area where adolescents were allowed to smoke was just outside the entrance, which everyone referred to as Adolescents at Lowsmoke perceived smoking as a norm-breaking behaviour; smokers did not feel completely comfortable smoking, and felt judged by others. We identified three shared smoking patterns that helped smokers cope with the negative judgements associated with smoking during school hours: Social bonding smoking, Low-profile smoking and Smoking-friendly event smoking.Where: just outside the school premises;When: every school break;With whom: daily smoking boys who isolate themselves as a group from non-smokers;Why : daily smoking is an indispensable part of their membership to a group that creates a smoking-tolerant environment.A group of boys smoked at the gate during all school breaks. These boys were slightly older than other adolescents and explicitly positioned their group as separate from the rest; \u201c[we] do not really engage with anyone else at school\u201d and \u201cabsolutely do not care about what others think [of us]\u201d (LMD). This group was difficult to join for outsiders, non-smokers in particular.\u201cSince a few years we have a group of friends that spend the school breaks together. A few months ago he [another student] suddenly joined us and now stands with us every time. He thinks he is part of us, but he never smokes. We all say to him \u2018why are you standing here, you don\u2019t even smoke?\u2019. We don\u2019t have friends standing with us that do not smoke\u201d (LM2).Smoking created a group vibe that does not exist without smoking. They talked about this vibe by referring to \u201cgood memories\u201d (LM1) when they were smoking together and how these thoughts made them want to smoke in social situations.They smoked together during school breaks because it had become a behavioural routine that was difficult to stop. Spending school breaks without smoking was not even considered an option, as they found it difficult not to smoke in the presence of their friends and were not closely befriended with most non-smokers.Boy1: \u201cIf you chose not to smoke, you\u2019ll be alone [without friends] in the school building as you do not know anyone.\u201d.Moderator: \u201cBut you could stand at the gate without smoking?\u201d.Boy1: \u201cYes that\u2019s true, but you know.\u201d.Boy2: \u201cThen you\u2019re offered a cigarette.\u201d.Boy1: \u201cThat\u2019s the danger\u201d (LMD).Boys smoking during free time between teaching hours was not as common as smoking during school breaks because they had different free periods due to individualized school timetables, depending on which courses they take. Smoking during school breaks was different as \u201cyou do it with everyone and so don\u2019t have to feel alone\u201d. (LM3) Smoking with others allowed them to hide in the crowd and therefore feel \u201cless looked at\u201d (LM1) like addicts.Boy: \u201cI don\u2019t do that [smoking during free time between teaching hours]. Then you have to stand alone at the gate. That looks strange, really like you\u2019re a junkie.\u201dInterviewer: \u201cWhy do you think so?\u201c.Boy: \u201cIt looks like you really cannot live without. That looks so horrible\u201d (LM3).Smoking almost exclusively with close friends was their way of creating a small smoking-tolerant environment in a larger smoking-intolerant school context.Where: first behind the flats, but since recently just outside school premises;When: when they occasionally feel like;With whom: girls who stand outside with their (non-)smoking friends;Why : smoking occasionally and only for pleasure prevents others from thinking that they are addicted or smoke to impress.There were a few groups of girls mixed of smokers and non-smokers. Smoking was not a prerequisite for group membership; \u201cif one of the girls smokes, the group stands outside [school premises].\u201d (LF1) Most girls did not want to smoke every school break or free hour and only smoked when they would enjoy it. Smoking was, for instance, strongly connected to enjoying being outside, \u201cparticularly when the weather is nice.\u201d (LF3)\u201cNot all of us smoke every day. You only smoke when you feel like it.\u201d (LF2).\u201cI smoke only sometimes at school. I don\u2019t have these urges where I think \u2018now I need a cigarette\u2019\u201d (LF4).These girls underpinned that they did not want to smoke every school break by explicitly distancing themselves from the boys that go out to smoke every school break.Girl: \u201cSometimes I see the boys of our school who smoke on a regular basis. They have so much desire [for a cigarette] and when I see it, I think \u2018I don\u2019t want to be like that\u201d (LFD).Formerly, the girls used to walk to nearby flats as they \u201cfelt ashamed to smoke near the school gate\u201d (LFD). These flats allowed them to smoke covertly so that fellow students and individuals passing the school would not notice them. School, however, recently prohibited them from smoking near these flats. The girls reasoned that school \u201cpurposefully decided that we are not allowed to smoke near the flats (\u2026) they know we feel ashamed to smoke at the gate, so they think we will stop smoking\u201d (LFD). They didn\u2019t stop smoking and instead started smoking occasionally at the gate. The girls explicitly stressed that they, in contrast to others, don\u2019t smoke at the gate to look cool and impress, but only smoke for authentic reasons, like for pleasure.\u201cYou smoke for yourself, not so that everyone can see it, right?\u201c (LF4).Where: socio-spatial environments where smoking is accepted;When: after school hours;With whom: anyone who is present;Why : feel free to smoke without risking negative social consequences.Some adolescent smokers refrained from smoking during school hours. They were afraid that fellow students will judge them harshly if they would find out that they smoke. They preferred to smoke during smoking-friendly events as they do not have to worry about the possibility that someone will negatively judge them for smoking.\u201cI have friends who say they don\u2019t smoke at school, but smoke during parties or when we sit on a terrace. They don\u2019t feel comfortable to smoke at school\u201d (LF4).This shared smoking pattern was predominantly attributed to girls because their smoking during school hours was easily judged as wanting to look cool and trying to impress.\u201cPeople will think badly about you [as a girl] and say that you smoke to look cool\u201d (LF1).These girls therefore wanted \u201cas little people as possible\u201d (LF2) to see that they smoke, so that \u201cnot everybody knows about it\u201d (LF3). Boys similarly mentioned that primarily girls experience such concerns, likely because they themselves argued not to care so much about other adolescents\u2019 opinions.\u201cShe has a lot of friends at school. She doesn\u2019t want to portray a picture of herself like \u2018look at me\u2019. So she smokes, but definitely not at school.\u201d (LM3).Adolescents who smoked during school hours also recognized these concerns, and therefore, preferred to smoke at social events where smoking is more accepted. Such environments allowed them to smoke without having to think of others\u2019 opinions.\u201cIt is not that I constantly think \u2018shit, these people are looking at me\u2019 (\u2026) but I just prefer to smoke on parties or whatever, because then it is more accepted\u201d (LM2).This study aimed to develop a better understanding about how adolescents\u2019 smoking during school hours persists in schools that have implemented SFSPs, by exploring whether adolescents in these schools show shared smoking patterns and, if so, what are the shared smoking pattern in these schools.Five shared smoking patterns were identified. Two shared smoking patterns were identified at Highsmoke. \u2018Dependent smoking\u2019  and \u2018Rebellious smoking\u2019 (smoking in friendship groups outside the school premises expresses toughness). Three shared smoking patterns were identified at Lowsmoke. \u2018Social bonding smoker\u2019 (boys\u2019 daily smoking outside the premises in an exclusive smokers\u2019 group creates a smoking-tolerant environment), \u2018Low-profile smoking\u2019  and \u2018Smoking-friendly event smoker\u2019 .A first limitation is that we collected data only at one point in time, and therefore, could not unravel the causal influence of SFSPs on the shared smoking patterns. The shared smoking patterns may have existed before SFSPs were implemented, and differences in SFSPs and shared smoking patterns could be related to differences in educational level and the smoking prevalence between both schools.A second limitation is that we did not take into account the socio-demographic characteristics of adolescents who participated in the FGD and interviews. Smokers from Lowsmoke may be intermittent smokers who come from social environments where smoking is frowned upon and smokers at Highsmoke may be heavy smokers who come from environments where smoking is part of daily life. Differences between schools may therefore be an indication of adolescents\u2019 general lifestyle rather than reflecting the school environment.A third limitation is that we included only two schools. This small number was the result of a collaborative decision made among researchers participating in the SILNE-R project to organise the FGDs only in two or three schools per country. In the Netherlands, FGDs were organized in three schools, yet one school did not allow the collection of additional interview data. Therefore, the generalizability of the precise shared smoking patterns may be limited.A fourth limitation is that we explored shared smoking patterns only with two FGDs and seven interviews per school. This data collection did not stop upon reaching theoretical data saturation, because we made a priori agreements with schools about the number of FGDs and interviews. We therefore cannot exclude that we missed out shared smoking patterns that are less overt or prevalent.Adolescents at Lowsmoke, in contrast to those at Highsmoke, perceived strong anti-smoking norms for smoking during school hours. This manifested in fundamentally different shared smoking patterns. The three shared smoking patterns at Lowsmoke responded to the anti-smoking norms by helping smokers cope with the experience of negative judgements for smoking, whereas the two shared smoking patterns at Highsmoke underscored the benefits of smoking. We will therefore discuss the shared smoking patterns in perspective of smoking denormalization, in particular its role in decreasing smoking  and incrSocial bonding smoking at Lowsmoke involved smoking daily as an indispensable part of membership to a group, to create a smoking-tolerant space within a smoking-intolerant environment. This indicates that adolescents may, in response to stigma, form friend groups that almost exclusively consist of and engage with daily smokers, contributing to smokers\u2019 self-induced social isolation from the increasing majority of non-smokers . This coLow-profile smoking at Lowsmoke involved smoking occasionally and only for authentic reasons, to prevent others from thinking that one is addicted or smokes to impress. These adolescents recognised the stigma related to smoking, but concurrently argued that good and bad ways of smoking exist. A good way of smoking is, in line with prior literature ,25, to sSmoking-friendly event smoking at Lowsmoke involved smoking only after school hours at smoking-friendly events to avoid risking negative social judgements. Adolescents talked about specific places where and times when smoking is more accepted, and deliberately went to these socio-spatial environments to smoke. Young adults were similarly shown to perceive smoking in bars and cafes in the weekend as settings where the normal expectations about abstaining from smoking do not apply . ScholarDependent smoking and Rebellious smoking at Highsmoke involved smoking at the designated smoking area to deal with stress and the need for nicotine, or smoking outside the premises to express toughness. These social meanings parallel views that were dominant before smoking became a deviation from societal norms , suggestDespite stark differences in the precise shared smoking patterns, the social dynamics between social in-groups and social out-groups showed commonalities between the two schools. Social bonding smoking (Lowsmoke) and Rebellious smoking (Highsmoke) both violated the norms to such extent that other smokers explicitly distanced themselves from the respective pattern at their school. Also, adolescents following one of these norm breaking patterns in either of the schools described themselves as an \u2018exclusive group\u2019 which is difficult to join for the majority of adolescents. On the other hand, Low-profile smoking (Lowsmoke) and Dependent smoking (Highsmoke) were relatively undefined and open for anyone who wants to smoke in a socially acceptable way.The strengthening of anti-smoking norms among adolescents is a primary causal mechanism underlying the impact of SFSPs . The resFirst, schools may prohibit smoking during school hours in or outside the premises. The only available study showed that complementing SFSPs with prohibitions from leaving the premises were associated with lower smoking rates compared to other SFSPs . These pSecond, schools may target pro-smoking social meanings that maintain specific forms of adolescent smoking behaviour. Key targets could be occasional smoking during  and after  school hours, because occasional smokers have an ambivalent attitude towards smoking. To date, no evidence exists about interventions that aim to address occasional smoking as a social-level phenomenon. Such interventions may be inspired by social design methods .Third, schools may create a physical environment that decreases the chances that adolescents start or continue following shared smoking patterns. A recent study, for instance, suggested that changing the school surrounding, among which creating a pleasant non-smoking area, may reduce progression from occasional to daily smoking .This exploratory study may inspire further research on adolescents\u2019 shared smoking patterns and how these contribute to persisting adolescent smoking. Future studies should use more rigorous research designs than ours. For example, Hargreaves et al.  studied Schools that have implemented smoke-free school policies are still confronted with adolescents who smoke during school hours. This was shown to be socially embedded in diverse shared smoking patterns that support adolescents in persisting in smoking, despite an increasingly smoking intolerant environment. We therefore suggest new studies that aim to develop more understanding on how to effectively target adolescents\u2019 shared smoking patterns, in an attempt to help further decrease adolescent smoking during and after the school hours."}
+{"text": "Neurosurgical patients are varied, encompassing cranial and spinal diseases and trauma, and are admitted under both elective and emergency settings. In all settings, neurosurgery patients are at risk of deep vein thrombosis. D-dimer and ultrasound Doppler have long been good screening and confirmatory tools for the diagnosis of deep vein thrombosis (DVT). We conducted a study to identify the factors associated with DVT among neurosurgical patients, and the overall rate of occurrence at our centre. We aimed to also compare our results to the incidence in similar studies elsewhere in which more judicious use of pharmacological prophylaxis was undertaken. We also included the Well\u2019s score to validate its usefulness in screening for DVT in our local setting.All patients admitted into our centre were screened for eligibility and those who underwent surgery from September 2016 to September 2017 had a D-dimer screening after surgery, followed by an ultrasound Doppler if the former was positive. The choice of anticoagulant therapy was not influenced by this study, and observation of the use was in keeping with usual practices in our centre was done.P < 0.05 for each.A total number of 331 patients were recruited in this study, however, after the inclusion and exclusion criteria had been met, 320 patients remained eligible, i.e. suitable for analysis. The mean age of our patients was 46 years, with 66% being male patients. A majority of the cases in this study were cranial related, with only 5% being spine surgeries. On the multivariate analysis, the Well\u2019s score and the number of days in bed remained statistically significant, after adjusting for age group, gender, ethnicity, type of central venous access and type of DVT prophylaxis with an adjusted odd\u2019s ratio, and a confidence interval of 95%, and Well\u2019s scoring and number of days in bed were independent factors affecting the rate of DVT in patients undergoing neurosurgical procedures in our centre. Venous thromboembolism is a significant health issue on a global scale, affecting a wide variety of people, for an equally wide variety of reasons. Deep vein thrombosis (DVT) is the formation of clots in the deep venous system of the body and primarily affects the large veins in the lower leg, thighs, and can also occur in deep veins of the arms and pelvis.The development of DVT is a constant risk in any hospital setting. Although most DVTs are occult and can resolve spontaneously, complications from it arises when the clot dislodges and blocks narrower veins of major organs such as the heart, lung and brain, which can result in catastrophic outcome. Prophylaxis of DVT is therefore an integral as part of any patient care.The pathophysiology of DVT is described in detail elsewhere, with Virhow\u2019s triad-hypercoagulability, stasis and endothelial damage, forming the basis of development of the disease process. A multitude of risk factors such as oral contraceptive pills, obesity, prolonged bed rest and immobility contribute to the added chances of developing DVT. Certain medical conditions such as malignancies and Factor V Leiden have also been shown to increase the risk of developing DVT , 2. DVT The reported incidences of DVT in neurosurgical patients are varied and range from 12.02% to 26.1% , 4. The In this study, we aimed to identify the risk factors associated with the development of DVT in neurosurgical patients, with the objective of being able to identify types of patients with the highest risks in our given cohort and therefore, to assist the neurosurgeon in deciding on patients who would benefit from more aggressive coverage with anticoagulants. We had also included Well\u2019s scoring to determine its validity in an inpatient neurosurgical setting as it was not a routine tool used for our patient assessment. We further looked at D-dimer values to compare with the limits that had been suggested in other studies.This is a prospective cohort study using non-probability sampling to determine the factors that are associated with, and the overall rate of, DVT among neurosurgery patients who have been admitted and subjected to surgery in Kuala Lumpur Hospital, between September 2016 to September 2017. The patient population, including those admitted under both elective and emergency settings, had undergone at least one neurosurgical procedure during that admission. No additional deep vein thrombosis prophylaxis was given for patients for the purpose of this study.Patients aged between 18\u201365 yearsAt least one neurosurgical procedure done during admissionPatients on anticoagulants, or a past history of venous thrombosisBed or wheelchair bound for more than 3 days prior to admissionPatients who were unable to give consent themselves, or via the next of kinAll patients who were selected after applying the inclusion and exclusion criteria underwent a D-dimer (Hemosil D-dimer IL ACL7000) screening three days after surgery. Using a screening value suggested in a study by Prell et al.,  a cut ofThe data we collected was keyed into the computer software Statistical Package for Social Sciences (SPSS) for Mac version 24.0. The data generally contained demographic information, DVT risk factors, surgical details, D-dimer as well as ultrasound Doppler findings. Demographic information was expressed in a table form as mean and standard deviation for numerical variables and number and percentage for categorical variable. The predictors of DVT were analysed with univariate logistic regression and multiple logistic regression to report on crude and adjusted respectively.n = 204), followed by Chinese (n = 82), Indians (n = 25) and lastly others (n = 9). This reflects a gross general population mix for the region. There were nearly twice as many males (n = 212) in our study compared to females (N = 108). The majority of cases were cranial (n = 304), the rest being spine surgeries (n = 16).A total number of 331 patients were recruited in this study, however, after the inclusion and exclusion criteria were met, 320 patients remained eligible i.e. suitable for analysis. The patients\u2019 demographics are depicted in n = 242). We further divided patients according to the Well\u2019s Score, into low risk (n = 280) if the score was less than 3 and high risk (n = 40) if the score was 3 or more. The choice of DVT prophylaxis among our subjects were compression stockings (n = 125), pneumatic cuff (n = 166), low molecular weight heparin (n = 23), while the remainder received none (n = 6). Most of the central venous access obtained in our patients were femoral (n = 233), followed by subclavian (n = 38), and jugular (n = 1) with the remainder not having any at all (n = 48).Most of the cases also came under emergency settings (n = 133) had results of more than 2 mg/L, with the remainder (n = 187) having results less than the chosen cut off value. From those who had been subjected to ultrasound Doppler, a total of 33 were confirmed to have DVT. This gave us an overall DVT rate of 10.3%, with a 95% confidence interval, 7%\u201313.6%.Our study subjected all patients to a D-dimer screening, of which over one third (P < 0.001), type of DVT prophylaxis (P < 0.014), increased number of days in bed (P < 0.029) and Well\u2019s score (P < 0.006) had significantly higher odds of developing DVT.Univariate logistic regression (with 1 to 1 association) was done for the characteristics of patients as a predictive indicator for development of DVT as shown in P = 0.029). Type of tumour was removed from the regression since there was only 1 observation of spinal tumour in positive diagnosis, making a comparison of rate between cranial and spinal neurosurgical tumour cases non-feasible.On the multivariate analysis, as depicted in DVT remains a common and potentially life-threatening complication in any inpatient setting. The incidence of DVT in neurosurgical centres can vary significantly from 7.9% to 29% . In manyWell\u2019s scoring has been validated in several studies in the risk stratification for the development of DVT. The use of this scoring system has also been established as a valid pretest tool for risk stratification in trauma patients in one other study , howeverIn our study, we report an overall incidence of DVT of 10.3%. We compare this with one study by Hendwood et al. , which hn = 16), meningiomas (n = 8) followed by GBM (n = 7). One study by Sawaya et al. , only 1 patient (n = 1) had a screening value of less than 4 mg/L. When comparing this to the D-dimer value from the study by Prell et al. (With regards to D-dimer screening values, our study showed that of the total number of positive ultrasound Doppler findings (l et al.  (value cWe had in our study the intention to collect more details from our participants such as the use of oral contraceptives, smoking and level of physical activities or regular exercise, however, where many of the patients who were unable to provide the answers themselves such as in the case of trauma, family members were uncertain of such details.The number of days in bed were grouped into a mean of 6, 13.5 and 16.5 days and as expected, the longer the patient remained in bed, the higher the risk of developing DVT.Our study revealed that the Well\u2019s scoring and the number of days in bed had remained the main factors that increased the risk of DVT development. Well\u2019s scoring is not documented routinely for the patients in our neurosurgery unit, accordingly, using the findings of this study the suggestion to make the Well\u2019s score charting as standard for all patients, to be included in the observation charts, has been made. This can help the department identify those who are at greater risks and to guide the neurosurgeon on considering additional modalities of DVT prevention, namely adding a pharmacological agent on a case to case basis, weighing in between the benefits versus the risks.Of all the patients who developed DVT, only one patient had passed away, however the cause of death was sepsis rather than as a result of the DVT itself.We would like to declare than there were no sponsors involved and no gratuities were obtained from conducting this study.In our study of the factors associated with DVT in neurosurgery patients and overall incidence in surgically operated cases, we found that only the Well\u2019s score and the number of days in bed were significant predictors of the risk for developing DVT when other confounders were adjusted. Those who were in the high risk groups of the Well\u2019s score were at a significantly higher risk of developing DVT, and with every passing day a patient remained non-ambulatory, the risk of DVT increases as well. Despite the use of mainly mechanical and single modality prophylaxis, the rate of occurrence was in fact fairly similar to other centres which used dual modality prophylaxis; suggesting that single modality can be considered for most cases, and advocating dual modality is for high risk cases only."}
+{"text": "Herein, we report a three-dimensional hierarchical assembly structure composed of an ultrathin Ru shell and a Ru-Ni alloy core as a catalyst functioning under universal pH conditions. Compared with the typical Ir/C-Pt/C system, superior catalytic performances and excellent durability of the overall water splitting under universal pH have been demonstrated. The introduction of Ni downshifts the d-band center of the Ru-Ni electrocatalysts, modulating the surface electronic environment. Density functional theory results reveal that the mutually restrictive d-band interaction lowers the binding of  and  for easier O-O and H-H formation. The structure-induced eg-dz  \u2022A facile method for the synthesis of 3D hierarchical assembly Ru-Ni NA catalyst\u2022Superior catalytic reactivity and stability of water splitting in universal pH\u2022The introduction of Ni can modify the d-band and surface electronic environment\u2022Minimization of the surface Coulomb repulsion leads to barrier-free catalysis process Catalysis; Energy Materials; Materials Science Water splitting consists of the hydrogen evolution reaction (HER) and oxygen evolution reaction (OER), both of which require efficient catalysts\u00a0to reduce the overpotential for practical applications (2 and oxygen (O2) under universal pH conditions is still a significant challenge.Hydrogen  consisting of ultrathin nanosheets as subunits and explore their high\u00a0performances for overall water splitting under universal pH conditions. The distinctive hierarchical NA structures are highly beneficial for enhancing electrochemical energy conversion. We found that the introduction of Ni into Ru largely downshifts the d-band center of the Ru-Ni NAs and effectively modulates the surface environment for HER. After air treatment at 350\u00b0C, the newly generated abundant RuO3), nickel(II) acetylacetonate (Ni(acac)2), phloroglucinol, tetramethylammonium bromide, polyvinylpyrrolidone (PVP), and benzyl alcohol into a glass vial. After capping the vial, the mixture was ultrasonicated for approximately 1 h. The resulting homogeneous mixture was then heated from room temperature to 160\u00b0C and maintained at 160\u00b0C for 5\u00a0h using an oil bath. Ru-Ni NAs with different Ru/Ni ratios  have been readily achieved by tuning the Ru/Ni precursor amount ratios  acetylacetonate (Ru(acac)t ratios A\u2013S1C.3Ni3 NAs were further carried out to determine the 3D assembly structure  plane of Ru and the (100) plane of the Ru-Ni alloy, respectively  plane of Ru. Lattice fringes of the (100) Ru-Ni alloy with interplanar distances of 0.231 and 0.232\u00a0nm were also observed in the Ru3Ni2 NAs and Ru3Ni1 NAs, respectively . \u22122, the overpotentials of Ru3Ni3 NAs, Ru3Ni2 NAs, Ru3Ni1 NAs, Ru NAs, and commercial Pt/C were 39, 42, 44, 62, and 90\u00a0mV, respectively, versus the reversible hydrogen electrode (RHE), and the Ru3Ni3 NAs showed the smallest value. The Tafel slope is an intrinsic property of the catalyst that is determined by the rate-limiting step of the HER  and Ru NAs (76.0\u00a0mV dec\u22121)  B. The Ru.1\u00a0M KOH F, which 3Ni3 NAs, Ru3Ni2 NAs, Ru3Ni1 NAs, and Ru NAs were 39 and 96\u00a0mV, 39 and 115\u00a0mV, 46 and 112\u00a0mV, and 55 and 122\u00a0mV at a current density of 10 mA cm\u22122 in 0.5\u00a0M H2SO4 and 0.05\u00a0M H2SO4, respectively. The Tafel slopes of the Ru3Ni3 NAs, Ru3Ni2 NAs, Ru3Ni1 NAs, and Ru NAs were 53.9 and 67.1\u00a0mV dec\u22121, 53.5 and 64.0\u00a0mV dec\u22121, 54.2 and 66.8\u00a0mV dec\u22121, and 81.6 and 79.6\u00a0mV dec\u22121 in 0.5\u00a0M H2SO4 and 0.05\u00a0M H2SO4, respectively. The Ru-Ni NAs showed a much better HER performance than the Ru\u00a0NAs, indicating the vital role of Ni in improving the HER performance. After the working electrode was cycled for 6,000 cycles, the Ru3Ni3 NAs exhibited the best durability under acidic conditions with potential increases of only 62 and 39\u00a0mV in 0.5\u00a0M H2SO4 and 0.05\u00a0M H2SO4, respectively. In addition, after the 12-h chronopotentiometry test at 5 mA cm\u22122 in 0.5\u00a0M H2SO4 and 0.05\u00a0M H2SO4, the Ru3Ni3 NAs showed only potential increases of 36 and 49\u00a0mV, respectively (The HER properties of the Ru-Ni NAs under acidic conditions were further investigated. 2SO4 and 1\u00a0M KOH). The TEM images show that the hierarchical structures were largely preserved  and alkaline (1 and 0.1\u00a0M KOH) electrolytes. The commercial Ir/C catalyst was chosen as the reference because Ir is considered to be the benchmark catalyst for OER  and commercial Ir/C (407\u00a0mV)  B. The Taectively D. All thtry test , which d 1\u00a0M KOH .3Ni3 NAs after air treatment at 250\u00b0C for 1\u00a0h and cathodic catalyst Ru3Ni3 NAs after air treatment at 350\u00b0C for 2\u00a0h was used to study the potential application of Ru-Ni NAs in overall water splitting under universal pH conditions. The Linear Sweep Voltammetry (LSV) plots of Ru3Ni3 NAs and Ir/C-Pt/C under different pH conditions are presented in 3Ni3 NAs are much lower than those of Ir/C-Pt/C. The Ru3Ni3 NAs show an overpotential of\u00a0280\u00a0mV in 0.5\u00a0M H2SO4, which is considerably lower than that of Ir/C-Pt/C (370\u00a0mV). The Tafel slope of the Ru3Ni3 NAs is only 96.9\u00a0mV dec\u22121, whereas that of Ir/C-Pt/C is as high as 150.1\u00a0mV dec\u22121 , Ru4+ (orange line), and Ru0 (dark yellow line) (4+ fractions in the Ru3Ni3 NAs (57.00%), Ru3Ni2 NAs (44.46%), and Ru3Ni1 NAs (44.57%) were much higher than those in the Ru NAs (29.89%)  and Ni3+ (orange line)  A (Li et\u00a0ow line) . It was (29.89%) , which cge line) . Ni3+ isformance . This rex+ (purple line), Ru4+ (orange line), and Ru0 (dark yellow line)  . It was  Ru NAs.  and indiC in air C and 5D.C in air . Pt is rC in air C and 5D,C in air .F) ]\u2192[O*+2(H++e\u2212)] (\u223c0.4 eV). An additional similarly energetic increase (1.50 eV) was found for the formation of *OOH, indicating that the O* on the Ru-Ni still stays active to oxidize OH under lower overpotential. The splitting of H for the [HOO*+3(H++e\u2212)]\u2192[O2+4(H++e\u2212)] transformation is very active. Compared with the pathway at U\u00a0= 1.23 V, we confirm the overall overpotential  is almost the same within the range of 0.200\u20130.300 V. Further calculations of the O2 dissociation confirmed that the combined O-O on the Ru-contained surface will be easily dissociated and enter into the surrounding solution conditions  is shown in absorption process in 2+ and O-p\u03c3 orbitals will facilitate the ion transfer. The distorted structure prompts Ru2+ (d6) to change from a low-spin state (t2g6eg0) to an intermediate-spin state (t2g5eg1), where the eg1 can point to the intermediate with high bonding possibility. We also find that the absorption energy of further absorption on vertical oxygen molecule will be lowered nearly 1\u00a0eV, which can be attributed to the Jahn-Teller effect from the extra oxygen molecule to the c-axis of the distorted octahedral unit, which decreases the whole energy. Electrons on t2g can be further excited to eg and then form a high-spin state (t2g4eg2) with energy decrease. Overall, the Ru-Ni catalytic system is found to be efficient in HER performance from acidic to the basic condition. Thus, the Ru-Ni (NAs) system exhibits a high catalytic reactivity for water splitting based on the DFT calculations. We have also made a detail comparison for the preliminary absorption behavior on the cubic Ru-Ni (111) and hexagonal close packed (hcp) Ru-Ni (001) surface to elucidate the experimental treatment and related analysis. The discussions and analysis cover the following sections: energetics, electronic structures, orbital energetic behaviors, and adsorption analysis  calculations to elucidate how the downshift effect of the Ru-Ni NAs is related to the high performance of water splitting for both the OER and HER. The Ru-Ni NA system was modeled by a hexagonal lattice (hex-Ru-Ni) based on the Ru local symmetry. It shows a good metallic behavior with uniform isotropic conductivity across the Fermi level (EF) A. The d-F) B due to e the EF B, regard pathway C shows tnditions  and S7.  surface D. At the surface E. We alsanalysis .Figure\u00a062-decorated Ru-Ni NAs treated at 350\u00b0C in air provided additional active sites for the OER. The combined structural and electronic engineering leads to superior electrocatalytic performance for overall water\u00a0splitting under universal pH conditions, and the performance is much better than that of the commercial Pt/C and Ir/C, demonstrating an unprecedented class of nanocatalysts with exceptional activity and excellent stability for electrochemical water splitting.In summary, for the first time, we have demonstrated a facile method for the synthesis of 3D Ru-Ni NAs, which leads to favorable 3D Ru-Ni superstructures with fully exposed active sites. The valence band spectra and DFT calculations revealed a change in the d-band center in the Ru-Ni NAs after the introduction of\u00a0Ni,\u00a0resulting in the transformation to a favorable surface environment for the OER and HER. The RuOOur work has demonstrated a novel bifunctional catalyst for water splitting in the universal environment from experimental and theoretical perspectives. Based on the combination of XPS and DFT as an effective approach, electronic environment modulation has been interpreted as the key factor that facilitates both\u00a0HER and OER. However, an in-depth understanding of the oxidation states of the catalyst is still an open challenge because of the complex charge transfer induced by the overlap between the metal orbitals as\u00a0well as the correspondingly accurate characterization. The site-to-site sampling and analysis of surface\u00a0oxidation sites is of great significance for precise understanding of the catalyst reactivity. Therefore, we will keep working on further development and perfection on related theoretical exploration and advancement.All methods can be found in the accompanying"}
+{"text": "EWSR1 gene with ETS transcription factors (in 85% FLI1). EWSR1-FLI1 induces gene expression via binding to enhancer-like GGAA-microsatellites, whose activity correlates with the number of consecutive GGAA-repeats. Herein we investigate the role of the secretory neuropeptide CALCB  in EwS, which signals via the CGRP  receptor complex, containing RAMP1 (receptor activity modifying protein 1) as crucial part for receptor specificity. Analysis of 2678 gene expression microarrays comprising 50 tumor entities and 71 normal tissue types revealed that CALCB is specifically and highly overexpressed in EwS. Time-course knockdown experiments showed that CALCB expression is tightly linked to that of EWSR1-FLI1. Consistently, gene set enrichment analyses of genes whose expression in primary EwS is correlated to that of CALCB indicated that it is co-expressed with other EWSR1-FLI1 target genes and associated with signatures involved in stemness and proliferation. Chromatin immunoprecipitation followed by sequencing (ChIP-seq) data for FLI1 and histone marks from EwS cell lines demonstrated that EWSR1-FLI1 binds to a GGAA-microsatellite close to CALCB, which exhibits characteristics of an active enhancer. Reporter assays confirmed the strong EWSR1-FLI1- and length-dependent enhancer activity of this GGAA-microsatellite. Mass spectrometric analyses of EwS cell culture supernatants demonstrated that CALCB is secreted by EwS cells. While short-term RNA interference-mediated CALCB knockdown had no effect on proliferation and clonogenic growth of EwS cells in vitro, its long-term knockdown decreased EwS growth in vitro and in vivo. Similarly, knockdown of RAMP1 reduced clonogenic/spheroidal growth and tumorigenicity, and small-molecule inhibitors directed against the RAMP1-comprising CGRP receptor reduced growth of EwS. Collectively, our findings suggest that CALCB is a direct EWSR1-FLI1 target and that targeting the CALCB/RAMP1 axis may offer a new therapeutic strategy for inhibition of EwS growth.Ewing sarcoma (EwS) is an aggressive cancer characterized by chromosomal translocations generating fusions of the  Since specific treatment options do not exist, current therapy concepts comprise local surgery combined with conventional poly-chemotherapy and irradiation1. Despite such intense conventional therapy, prognosis of patients with metastatic disease still remains poor2. Thus specific and, in particular, less toxic treatment options are urgently required.Ewing sarcoma (EwS) is a malignant tumor of bone and soft tissue predominantly affecting children and adolescentsEWSR1 gene on chromosome 22 (chr22) and various members of the ETS family of transcription factors\u2014most commonly FLI1 on chr11 (85% of cases)1. EWSR1-FLI1 can arise either through balanced chromosomal translocations or through complex genomic breakage/fusion events4. Notably, EWSR1-FLI1 encodes an aberrant chimeric transcription factor, which binds DNA at ETS-binding site-like GGAA-motifs and furthermore at GGAA-microsatellites consisting of multiple sequential GGAA-motifs5. While EWSR1-FLI1 binding at single ETS binding site-like motifs in gene promoters either activates or represses gene transcription, EWSR1-FLI1 binding at GGAA-microsatellites creates de novo enhancers, whose activity correlates positively with the number of consecutive GGAA-repeats7.EwS is characterized by gene fusions involving the EWSR1-ETS translocations being virtually the only highly recurrent somatic mutation in EwS9. Although EwS is genetically well characterized, its precise cell of origin remains controversial. Transcriptome profiling and functional studies suggested that EwS may arise from mesoderm- or neural crest-derived mesenchymal stem cells11. Owing to this histogenic uncertainty, there is currently no bona fide genetically engineered animal model available for EwS, which hampers the development of new therapeutic strategies12. Like many other ligand-independent transcription factor oncoproteins, EWSR1-FLI1 also proved to be notoriously difficult to target13. However, the EWSR1-FLI1-induced transcriptomic signature may harbor specific changes that could be exploited therapeutically.Recent sequencing efforts revealed CALCB , which encodes a neuropeptide that was already described in 1987 to be highly expressed in EwS cell lines15. Nevertheless, its functional effects in EwS have remained unexplored until now.To explore such EWSR1-FLI1 surrogate targets, we focused in this study on the putative EWSR1-FLI1 target gene CALCB gene is located next to its homolog CALCA  on chr11p15.2 and encodes a secretory neuropeptide composed of 37 amino acids17. CALCB is predominantly expressed in the central nervous system and causes potent vasodilatation19. Signaling of both CALCA and CALCB is mediated through G protein-coupled receptor complexes present on the cell surface. There is a variety of different receptors, formed by heterodimerization, which recognize both peptides. Most importantly they are recognized by the so called CGRP receptor, which is formed by the calcitonin receptor-like receptor  and RAMP1 (receptor activity-modifying protein 1). RAMP1 makes the receptor complex specific for the binding of CALCA and CALCB21. Receptor\u2013ligand interaction leads to G protein-mediated increase in intracellular cAMP levels22. Apart from the above-described CGRP receptor, CALCB also binds to a receptor complex consisting of RAMP1 and the calcitonin receptor , which is called AMY1 (amylin subtype 1) receptor. However, this receptor is not specific for CALCA and CALCB but is also activated by binding of islet amyloid polypeptide (IAPP). Since the biological role of AMY1 is not fully understood, and given that both CALCR and IAPP are not or only barely expressed in EwS .Here we show that 23. Data generated on Affymetrix HG-U133Plus2.0 microarrays were normalized simultaneously by Robust Multi-chip Average (RMA) using brainarray chip description files  yielding one optimized probe-set per gene25. Accession codes of used datasets are given in Supplementary Table\u00a0The microarray datasets for cancer and normal tissues were downloaded from public repositories and processed as described previously26. A673/TR/shEF1 cells, which contain a doxycycline (dox)-inducible short hairpin RNA (shRNA) against EWSR1-FLI1, were kindly provided by J. Alonso 27. All cell lines were grown at 37\u2009\u00b0C and 5% CO2 in a humidified atmosphere. RPMI 1640 medium with stable glutamine , 10% tetracycline-free fetal calf serum , 100\u2009U/ml penicillin (Biochrom), and 100\u2009\u00b5g/ml streptomycin (Biochrom) was used as standard medium to grow the cells. For cell lines, which tend to grow in suspension, TPP cell culture flasks  were coated with 1:40 phosphate-buffered saline (PBS)-diluted (Biochrom) collagen solution  to enable adherent growth. Cells were routinely checked for mycoplasma infection by nested PCR. Cell line purity was confirmed by Short Tandem Repeat profiling.A673, HEK-293T, and SK-PN-DW cells were purchased from the American Type Culture Collection . RDES, SK-ES1, SK-N-MC, and MHH-ES1 cells were provided by the German Collection of Microorganisms and Cell Cultures . TC-71 cells were kindly provided by the Children\u2019s Oncology Group and ES7, EW-1, EW-3, EW-7, EW-16, EW-18, EW-22, EW-24, LAP35, MIC, ORS, POE, SKNPLI, and STA-ET1 cells were provided by O. Delattre . SB-KMS-KS1 was established in the Department of Pediatrics at the TU Munich  and described previously\u2212\u0394\u0394CT method28. RPLP0 served as housekeeping gene. Primer sequences were as follows:RNA for analysis of gene expression with qRT-PCR from cell lysates and frozen tumor tissue was extracted using the NucleoSpin RNA Kit . Subsequent reverse transcription was performed with the High Capacity cDNA Reverse Transcription Kit  utilizing 1\u2009\u00b5g RNA per reaction and following the manufacturers\u2019 protocols of both kits. qRT-PCRs were performed using SYBR green  with a total volume of 15\u2009\u00b5l. cDNA was diluted 1:10 and concentration of primers was 0.5\u2009\u00b5M. Oligonucleotides were purchased from MWG Eurofins Genomics . Expression levels were determined with the CFX Connect Real time PCR Cycler  in a two-step protocol: initial enzyme activation and denaturation at 95\u2009\u00b0C for 2\u2009min, denaturation at 95\u2009\u00b0C for 10\u2009s, and annealing and extension at 60\u2009\u00b0C for 20\u2009s (repeating the last two steps 49 times), followed by a melting curve starting at 55\u2009\u00b0C and increasing by 0.5\u2009\u00b0C every 10\u2009s until a temperature of 95\u2009\u00b0C was reached. Expression levels were calculated according to the 2RPLP0 forward, 5\u2019-GAAACTCTGCATTCTCGCTTC-3\u2019;RPLP0 reverse, 5\u2019-GGTGTAATCCGTCTCCACAG-3\u2019;EWSR1-FLI1 forward, 5\u2019-GCCAAGCTCCAAGTCAATATAGC-3\u2019;EWSR1-FLI1 reverse, 5\u2019-GAGGCCAGAATTCATGTTATTGC-3\u2019;CALCB forward, 5\u2019-GCTCTCAGTATCTTGGTCCTG-3\u2019;CALCB reverse, 5\u2019-CACATAGTCCTGCACCAGTG-3\u2019;RAMP1 forward, 5\u2019-CCCAGTTCCAGGTAGACATG-3\u2019;RAMP1 reverse, 5\u2019-CCAGCTTCTCCGCCATGTG-3\u2019.CALCB expression was determined using qRT-PCR as described. CALCB expression levels were calculated relative to that of the A673 EwS cell line.Different EwS cell lines were cultured under standard conditions. After a minimum of 48\u2009h of culture, cells were harvested at a confluency of approximately 80%, and RNA extraction was carried out. 6 A673/TR/shEF1 EwS cells, which harbor a dox-inducible shRNA against EWSR1-FLI1, were injected subcutaneously in the flanks of immunocompromised NSG (Nod/scid/gamma) mice. When tumors reached an average volume of 180\u2009mm3, mice were randomized and either received 2\u2009mg/ml dox  and 5% sucrose (Sigma-Aldrich/Merck Millipore) in the drinking water (dox+) or only 5% sucrose (dox\u2212). Mice were sacrificed 96\u2009h after beginning of dox treatment, and tumors were collected for RNA analysis. Total RNA was extracted using the ReliaPrep miRNA Cell and Tissue Miniprep System . Knockdown of EWSR1-FLI1 was confirmed by qRT-PCR and proved EWSR1-FLI1 expression to be downregulated to 15% of the control (dox\u2212). Tumor purity (>95%) was confirmed in routine histology (hematoxylin and eosin [H&E] stains). The transcriptomes of 3 tumors of each group were profiled on Affymetrix Clariom D arrays (RNA integrity number >9). Microarray data were simultaneously normalized on gene level using Signal Space Transformation RMA and Affymetrix CDF as described29.For analysis of in vivo CALCB expression dependence on EWSR1-FLI1, 5\u2009\u00d7\u2009107 and the ENCODE project30, processed as described31, and displayed in the UCSC genome browser. The used samples are available under the following accession codes:Publicly available data were retrieved from the Gene Expression Omnibus GSM736570 ENCODE_SKNMC_hg19_DNAseHS_rep2;GSM1517546 SKNMC.shGFP96.FLI1;GSM1517555 SKNMC.shFLI196.FLI1;GSM1517548 SK-N-MC_shGFP_96h_H3K4me1;GSM1517557 SK-N-MC_shFLI1_96h_H3K4me1;GSM1517547 SKNMC.shGFP96.H3K27ac;GSM1517556 SKNMC.shFLI196.H3K27ac;GSM1517569 A673.shGFP48.FLI1;GSM1517572 A673.shFLI148.FLI1;GSM1517571 A673.shGFP96.H3.k27ac;GSM1517574 A673.shFLI196.H3K27ac.CALCB-associated GGAA-microsatellite was cloned from two different EwS cell lines (TC-71 and MHH-ES1) by PCR into the pGL3 Luciferase Reporter Vector (Promega) using the In-Fusion HD Cloning Kit . The DNA from the cell lines was extracted using the NucleoSpin Tissue genomic DNA Prep Kit (Macherey-Nagel) and digested with the restriction enzymes Eco-RV and SphI , followed by a fragment separation by gel electrophoresis, and fragment purification of the band at 8200\u2009bp using the NucleoSpin Gel and PCR Clean-up Kit (Macherey-Nagel). A touch-down PCR was performed with 100\u2009ng of the purified DNA fragment using the Infusion-Primers:A 359 base pairs (bp) fragment around the forward: 5\u2019-ctagcccgggctcgagGAGCCCTTTAGTATCCCCTTTG-3\u2019;reverse: 5\u2019-gatcgcagatctcgagACCCTTGTACTAACATGCTTCG-3\u2019,Escherichia coli Stellar competent cells (Clontech) were transformed with the DNA of the infusion mixture. Bacteria were grown on agar plates supplemented with ampicillin at a final concentration of 100\u2009\u00b5g/ml (Sigma-Aldrich/Merck Millipore) overnight at 37\u2009\u00b0C. Colonies were picked the next morning and checked for clones containing the plasmid with the insert by colony PCR. Positive clones were incubated overnight in LB broth (Miller)-medium with 100\u2009\u00b5g/ml ampicillin (Sigma-Aldrich/Merck Millipore) at 37\u2009\u00b0C, and plasmids were purified using the PureYield Plasmid Midiprep System 2 (Promega). The identity of the fragment was validated by Sanger sequencing .(MWG Eurofins Genomics) at a concentration of 0.5\u2009\u00b5M, and the components of the Go Taq Hot Start Polymerase Kit (Promega) according to the manufacturer\u2019s instructions. The thermal protocol was as follows: activation at 95\u2009\u00b0C for 2\u2009min, followed by 20 cycles of 98\u2009\u00b0C for 10\u2009s, 59-49\u2009\u00b0C for 30\u2009s (decreasing 0.5\u2009\u00b0C in each cycle), and 72\u2009\u00b0C for 1\u2009min, finalizing at 72\u2009\u00b0C for 5\u2009min. The PCR product was separated by gel electrophoresis, and the desired fragment of 359\u2009bp was purified with the NucleoSpin Gel and PCR Clean-up Kit (Macherey-Nagel). The reaction with the In-Fusion HD Cloning Kit (Clontech) was initiated using 10\u2009ng of the linearized pGL3 Luciferase Reporter Vector (Promega), digested with XhoI (NEB) and prepared according to the manual, and 20\u2009ng of the purified DNA fragment. The reaction was incubated at 50\u2009\u00b0C for 15\u2009min, stopped on ice for 5\u2009min, and 5 A673/TR/shEF1 EwS cells, harboring a dox-inducible shRNA against EWSR1-FLI1, were plated in a well of a 6-well plate  in 1.8\u2009ml of growth medium and transfected with the microsatellite-containing pGL3-luc vector and Renilla pGL3-Rluc vector (ratio 100:1) using Lipofectamine LTX with Plus Reagent (Thermo Fisher Scientific). Transfection medium was replaced by media with/without dox  4\u2009h after transfection. After 72\u2009h, the cells were lysed and assayed with a dual luciferase assay system . Firefly luciferase activity was normalized to Renilla luciferase activity.For the luciferase reporter assay, 2\u2009\u00d7\u200910CALCB in normalized gene expression data from 166 primary EwS32, GSEA was performed on lists of genes ranked by their correlation coefficient with CALCB . GSEA was carried out with 1000 permutations in default settings33.To identify gene signatures and biological processes associated with CALCB or RAMP1 (MWG Eurofins Genomics) were cloned in the pLKO-Tet-on-all-in-one system  as described previously34. Lentivirus production was performed in HEK-293T cells. A673 and RDES EwS cells were infected with the respective lentiviruses and selected with 1.5\u2009\u00b5g/ml puromycin . Single-cell cloning was performed, and knockdown efficacy of individual clones was assessed by qRT-PCR 48\u2009h after addition of dox . The shRNA target sequences were as follows:For generation of EwS cell lines with dox-inducible constructs (here in A673 and RDES), either a non-targeting negative control shRNA (MWG Eurofins Genomics) or specific shRNAs targeting shControl, 5\u2019-CAACAAGATGAAGAGCACCAA-3\u2019;shCALCB1, 5\u2018-AAGGAATGAAACTGAATGCAA-3\u2019;shCALCB4, 5\u2019-AACCTTGGTGATGCATTACAA-3\u2019;shRAMP1_3, 5\u2019-GCGCACTGAGGGCATTGTGTA-3\u2019;shRAMP1_4, 5\u2019-TGCCTGCCAGGAGGCTAACTA-3\u2019.5 cells were seeded in 6-well plates  in 1.5\u2009ml of standard growth medium. Gene knockdown was induced by addition of 1\u2009\u00b5g/ml dox (VWR/Merck) to the growth medium (refreshed every 48\u201372\u2009h) of cells harboring an inducible shRNA against CALCB or by serial transfections with 25\u2009nM small interfering RNA (siRNA) directed against CALCB  or a scrambled control siRNA  following the manufacturer\u2019s handbook of the transfection reagent HiPerfect (QIAGEN). After 2\u20134\u2009h, 3\u2009ml of standard growth medium was added to prevent toxic effects of the transfection reagent. After 24\u2009h, the medium was exchanged and after another 24\u2009h a second transfection was performed. Cell counts were determined by using standardized hemocytometers  and Trypan-blue (Sigma-Aldrich/Merck Millipore) exclusion 72\u2009h after seeding in the short-term proliferation assay and 6\u20139 days after seeding in the long-term proliferation assay.A total of 1\u20135\u2009\u00d7\u200910CALCB or RAMP1 or RDES wild-type cells were seeded at concentrations of 100\u20131 000 cells per well of 12-well plates and grown in standard culture medium for 12\u201314 days. Cells were treated with/without 1\u2009\u00b5g/ml dox (VWR/Merck) and RDES wild-type cells were serially transfected with a non-targeting siRNA or siRNAs against CALCB (as described above). Twice gently PBS-washed (Biochrom) colonies were stained with 500\u2009\u00b5l crystal violet (Sigma-Aldrich/Merck Millipore) and the number of colonies was quantified using ImageJ.A673 and RDES EwS cells harboring a dox-inducible shRNA construct against CALCB or RAMP1 were seeded at a density of 1000 cells per well of ultra-low attachment 96-well plates  in 80\u2009\u00b5l standard cell culture medium with/without dox . The culture medium was refreshed by adding 10\u2009\u00b5l medium with/without dox on top every second day. Spheroidal growth was monitored for 14 days. Thereafter, phase-contrast imaging and morphological analyses of spheres were carried out with an inverted Zeiss Axiovert 25 microscope  equipped with a Zeiss Axiocam 105 color camera . Sphere numbers and diameters were analyzed with ImageJ.For analysis of three-dimensional (3D) sphere formation, A673 and RDES EwS cells harboring a dox-inducible shRNA construct against 6 A673 EwS cells harboring a dox-inducible shRNA construct against CALCB or RAMP1 or a non-targeting control shRNA (shControl) were injected subcutaneously in NSG mice. After 10\u201314 days, when tumors were first palpable, mice were randomized and thereafter received either 2\u2009mg/ml dox (bela-pharm) dissolved in sterile water containing 5% sucrose (Sigma-Aldrich/Merck Millipore) (dox+) or sterile water with 5% sucrose alone (dox\u2212). Tumor growth was monitored with a caliper every other day and mice were sacrificed by cervical dislocation when the tumors exceeded an average diameter of 15\u2009mm (prior start of the experiment defined as \u201cevent\u201d). Experiments were approved by the government of Upper Bavaria and conducted in accordance with ARRIVE guidelines and recommendations of the European Community (86/609/EEC) and UKCCCR .A total of 2.5\u2009\u00d7\u200910RAMP1, were seeded at a density of 1500 cells per well of a 96-well plate  in 50\u2009\u00b5l standard growth medium with/without dox . After 24\u2009h of incubation, treatment was started by addition of 50\u2009\u00b5l standard growth medium containing either different concentrations of the CGRP receptor inhibitor MK-3207  dissolved in dimethyl sulfoxide  or the corresponding concentration of DMSO alone and dox refreshment for dox+ wells. After 72\u2009h, read-out was performed by addition of 20\u2009\u00b5l of 1:10 dissolved Resazurin  to the cells and measurement of fluorescence with a plate reader (Thermo Fisher Scientific) after 7\u2009h of incubation.A673 and A673/TR/shRAMP1_4 EwS cells, the latter harboring a dox-inducible shRNA against For analysis of two-dimensional (2D) colony-formation capacity under inhibitor treatment, A673 and RDES EwS cells were seeded at a density of 100 cells per well of 12-well plates  in 1\u2009ml culture medium. Forty-eight hours after seeding, inhibitors were added at final concentrations of 100\u2009\u00b5M for BIBN-4096  and 20\u2009\u00b5M for MK-3207 (AdooQ Bioscience). DMSO (Sigma-Aldrich/Merck Millipore) served as control. After 1\u20133 weeks, colonies were gently washed twice with PBS (Biochrom) and stained with 500\u2009\u00b5l crystal violet solution (Sigma-Aldrich/Merck Millipore). Colonies were photographed, and the number of colonies was counted using Image J.For analysis of 3D sphere-formation capacity under inhibitor treatment, A673 and RDES EwS cells were seeded at a density of 1000 cells per well in 80\u2009\u00b5l culture medium in wells of 96-well ultra-low attachment culture plates (Corning). After 24\u2009h of incubation, 20\u2009\u00b5l culture medium containing either inhibitor or DSMO  was added to the wells resulting in a final concentration of 100\u2009\u00b5M BIBN-4096  or 20\u2009\u00b5M MK-3207 (AdooQ Bioscience), respectively. After 14 days, spheres were photographed, and their number and size were analyzed using ImageJ.Available tissue microarrays (TMA) of primary EwS tumors containing 2 cores of each sample, with a diameter of 1\u2009mm, as well as internal controls were stained for CALCB. Analysis were carried out with approval from LMU Munich ethics committee.35 in 6\u201311 representative high-power fields (\u00d740) per xenograft with/without qRT-PCR-confirmed knockdown of CALCB.For IHC, 4-\u03bcm sections were cut and antigen retrieval was carried out by heat treatment using target unmasking fluid . Slides were incubated for 60\u2009min at room temperature with a rabbit polyclonal anti-CALCB antibody . Then slides were incubated with a secondary anti-rabbit IgG antibody  followed by target detection using DAB plus . Counterstaining was performed with Hematoxylin Gill\u2019s Formula (Vector). Intensity of CALCB staining was scored independently by two researchers on a scale from 0 to 2 . Specificity of the anti-CALCB-antibody was assured by determination of immunoreactivity scores (IRSs) using the Remmele and Stegner scoring systemFor CD31 staining, 4-\u00b5m sections of formalin-fixed and paraffin-embedded tumor tissue derived from EwS xenografts in mice were cut and heat treated using the Target Retrieval Solution (Agilent Technologies). Thereafter, tissue slides were stained with a primary monoclonal rat anti-CD31-antibody . As secondary antibody, a biotinylated and mouse-absorbed anti-rat-IgG-antibody  was used. After Streptavidin horseradish peroxidase  treatment, DAB plus (Agilent Technologies) was used for target detection. The slides were counterstained with Hematoxylin Gill\u2019s Formula (Vector).36. To this end, the number of overlaps of a CD31-positive cell with a dot of the Chalkley-grid in each quarter of the grid in four independent regions of the CD31-stained slide was counted, and the mean vessel density of the tumor was extrapolated.For evaluation of the microvessel density in the CD31-stained slides, the Chalkley-grid method was usedCALCB or RAMP1, respectively. The average area of necrotic tissue over the total tissue area as well as the number of mitoses per tumor sample was determined by a data-blinded resident pathologist through evaluation of 10 high-power fields (\u00d740) per slide.The average number of mitotic cells per high-power field was determined in 22 representative A673/TR/shCALCB xenografts and 10 A673/TR/shRAMP1 xenografts in H&E-stained slides with/without knockdown of 6 cells per T150 flask  in 20\u2009ml of standard culture medium. After 48\u2009h, the supernatant from the cells was removed, and the cells were washed with PBS (Biochrom) twice. Thereafter, the cells were grown for further 24\u2009h in 20\u2009ml Opti-MEM (Thermo Fisher Scientific) only. Afterwards, the supernatants were collected and immediately frozen at \u221280\u2009\u00b0C until the mass spectrometry was performed at the Antibody Engineering and Proteomics facility of the Immunity and Infection Research Centre . For mass spectrometric analysis, samples were lyophilized and resuspended in 50mM ammonium bicarbonate. In total 200\u2009\u03bcg of protein was reduced and alkylated using 10\u2009mM dithiothreitol (Thermo Fisher Scientific) and 100\u2009mM iodoacetamide (Sigma-Aldrich/Merck Millipore), respectively. Next, samples were digested using 20\u2009ng/\u03bcl trypsin (NEB) for 18\u2009h at 37\u2009\u00b0C. Samples were separated in a Nano-HPLC  using a C18 column and a gradient composed of solvent A (5% acetonitrile) and solvent B (95% acetonitrile). The program was: 5% acetonitrile for 5\u2009min, 5\u2013100% for 50\u2009min, and 100% for 10\u2009min. Eluted samples were spotted (Eksigent) on a 384-well plate and 1\u2009\u03bcl of the matrix \u03b1-cyano-4-hydroxycinnamic acid (10\u2009mg/ml in 50% acetonitrile and 0.1% trifluoroacetic acid) was added. The mass spectrometric analysis was performed on a MALDI-TOF/TOF 4800 (Sciex) using positive mode. The data were analyzed with the Trans-Proteomic Pipeline . To identify the peptide profile, a full-length synthetic CALCB polypeptide  was processed as a standard and analyzed. The peptide 106SNFVPTNVGSK116  was used to identify the presence of CALCB in the samples.A673 EwS cells were seeded at a density of 4\u2009\u00d7\u200910CALCB as being highly overexpressed in EwS compared to most tumor entities and all normal tissues except for trigeminal ganglia  by qRT-PCR. The results showed that the expression of CALCB is tightly linked to that of EWSR1-FLI1  and found strong EWSR1-FLI1 binding at intron 5 of the longest isoform (isoform 3) of the cer Fig.\u00a0. Knockdocer Fig.\u00a0.Fig. 2CAEWSR1-FLI1. In these assays, we observed strong enhancer activity of the GGAA-microsatellite, which was significantly diminished upon EWSR1-FLI1 knockdown  as compared to MHH-ES1 EwS cells (9 repeats), we noted a higher enhancer activity of the GGAA-microsatellite derived from TC-71 as compared to the microsatellite derived from MHH-ES1 in luciferase assays  into the pGL3 luciferase reporter vector and performed reporter assays in A673/TR/shEF1 cells with/without silencing of own Fig.\u00a0. In accoays Fig.\u00a0. CollectCALCB co-expressed genes in a transcriptome dataset of 166 primary EwS32. GSEA revealed that CALCB is co-expressed with other EWSR1-FLI1 target genes (ZHANG_TARGETS_OF_EWSR1-FLI1_FUSION)37 and with gene signatures involved in stemness and proliferation , which showed relatively high or moderate RAMP1\u2014the crucial component of the CALCB receptor complex\u2014phenocopied the effect of CALCB knockdown in clonogenic growth assays , or alternatively by circulating murine Calcb, which might have compensated at least in part for the loss of human CALCB.In our long-term knockdown experiments, we observed that silencing of CALCB or RAMP1 knockdown. CGRP receptor inhibitors already showed high efficacy in the treatment of migraine, which is presumably caused via CALCA- or CALCB-mediated vasodilatation in the vicinity of the trigeminal ganglia\u2014the only normal tissue type with physiologically high CALCB expression levels found in our analyses. We speculate that repurposing and further optimization of such \u201cmigraine drugs\u201d 38 could perhaps offer novel therapeutic options for EwS patients in the future. As we did not observe differences in density of tumor-associated blood vessels quantified by staining for murine CD31 in IHC of our xenograft experiments (Supplementary Fig.\u00a039.In our drug\u2013response assays, we found that inhibition of CGRP receptors with two different small molecules had a similar antiproliferative effect on EwS cells to that of the CALCB as a highly specifically expressed EWSR1-FLI1 target gene encoding a secreted peptide that promotes growth of EwS cells, and show that targeting the CALCB/RAMP1 axis in EwS may offer a new therapeutic approach. Future studies will have to dissect the precise downstream signaling and how the CALCB/RAMP1 axis promotes proliferation of EwS cells to further explore its therapeutic potential.Collectively, we identified Supplementary Figures 1-7Supplementary Tables 1 & 2"}
+{"text": "The formed structure also resulted in enhanced thermal stability and viscosity. These findings provide critical implications for the application of \u03b2-lactoglobulin and gum arabic complexes in food research and industry.Protein\u2013polysaccharide complexes have received increasing attention as delivery systems to improve the stability and bioavailability of multiple bioactive compounds. However, deep and comprehensive understanding of the interactions between proteins and polysaccharides is still required for enhancing their loading efficiency and facilitating targeted delivery. In this study, we fabricated a type of protein\u2013polysaccharide complexes using food-grade materials of \u03b2-lactoglobulin (\u03b2-Lg) and gum arabic (GA). The formation and characteristics of \u03b2-Lg\u2013GA complexes were investigated by determining the influence of pH and other factors on their turbidity, zeta-potential, particle size and rheology. Results demonstrated that the \u03b2-Lg and GA suspension experienced four regimes including co-soluble polymers, soluble complexes, insoluble complexes and co-soluble polymers when the pH ranged from 1.2 to 7 and that \u03b2-Lg\u2013GA complexes formed in large quantities at pH 4.2. An increased ratio of \u03b2-Lg in the mixtures was found to promote the formation of \u03b2-Lg and GA complexes, and the optimal \u03b2-Lg/GA ratio was found to be 2:1. The electrostatic interactions between the NH Protein\u2212polysaccharide complexes have received increasing attention since they possesses multiple advantages over other delivery systems . First, Although protein and polysaccharide complexes have been extensively studied previously ,12,13,14In this study, the influence of different factors, including protein\u2013polysaccharide ratio, ionic strength, heat and especially the pH, on the formation and properties of \u03b2-Lg\u2013GA complexes was investigated using UV\u2013visible (UV\u2013vis) spectroscopy, fluorescence spectroscopy, zeta-sizer, dynamic light scattering, infrared spectroscopy and rotational rheometry. The results will provide important implications for understanding the interaction between proteins and polysaccharides, facilitating the rational design of protein\u2013polysaccharide complexes and evaluating the possibility of further applications of \u03b2-Lg\u2013GA complexes in the food industry.\u03b2-Lactoglobulin (90% \u03b2-Lg) was purchased from Sigma. Gum arabic (GA) was purchased from Aladdin Reagent ). HCl (36\u201338%) was purchased from Shuanglin Chemical Reagent Factory . All other reagents were purchased from Aladdin Reagent and were of analytical grade.w:v) separately, and the pH of the solutions was adjusted to 7.0 using HCl and NaOH solutions with gradient concentrations, including 1 M, 0.1 M and 0.01 M. They were stored at 4 \u00b0C overnight until the polymers were fully dissolved. Then, \u03b2-Lg and GA were mixed at different ratios to make the \u03b2-Lg\u2212GA mixture. For preparing \u03b2-Lg\u2013GA coacervations, \u03b2-Lg solution and GA solution were mixed at the ratio of 2:1 and the mixed solution was adjusted by HCl and NaOH solutions until the pH was 4.0. Usually, several drops are needed so that the overall ionic strength will not be influenced. The mixture solution was centrifuged at 17.5 G  for 15 min and the lower phase was collected and subjected to freeze-drying .\u03b2-Lg (1 g) and GA (1 g) were dissolved in 100 mL deionized water  and temperatures (30\u201350 \u00b0C). Turbidity was calculated according to the following Equation (1):0 is the ratio of the intensity of the emergent and incident light. Measurements were carried out in triplicate.The turbidity of \u03b2-Lg\u2212GA mixed solutions was determined by a UV\u2013Vis spectrophotometer  at the wavelength of 600 nm (OD 600 nm) under the conditions of different pH values (1.6\u20137.0), NaCl concentrations (0\u201350 mmol/L), \u03b2-Lg/GA ratios (The effect of pH on \u03b2-Lg\u2212GA complexes with a \u03b2-Lg/GA ratio of 2:1 (0.05%:0.025%) was evaluated using UV\u2013vis spectroscopy under a scanning wavelength ranging from 220 nm to 400 nm.The effect of pH on \u03b2-Lg\u2212GA complexes with a \u03b2-Lg/GA ratio of 2:1 (0.05%:0.025%) was also determined by fluorescence spectroscopy  with the parameters set as follows: (a) endogenous fluorescence: the excitation wavelength was 290 nm and the range of the scanning wavelength was 220\u2013400 nm and (b) synchronous fluorescence: the excitation wavelength was 220 nm. The differences between the excitation wavelength and the initial scanning wavelength of 15 nm and 60 nm were selected.The zeta potentials of \u03b2-Lg solution, GA solution and \u03b2-Lg\u2212GA complex solution at different pH were measured by a zeta-sizer  at 25 \u00b0C. Using the same instrument, particle size distributions of \u03b2-Lg\u2212GA complexes at different pH values were also evaluated. All samples were tested at least for three times in parallel and their mean value was calculated.\u22121.The effect of pH on the apparent viscosity of GA solution and \u03b2-Lg\u2212GA solution was determined by a rotary rheometer . Two plates with the diameter of 60 mm were chosen and the set gap between them was 1.0 mm. Samples were placed between the two plates and equilibrated for two minutes before the apparent viscosity was measured at shear rates of 0.1\u2013100 sw/w) and made into pellets. Then, they were compressed to form transparent slices in the mold. Each sample was scanned for 32 times by an FTIR spectrometer  at a resolution of 4 cm\u22121 in the wavelength range of 4000\u2013400 cm\u22121 at room temperature.\u03b2-Lg, GA and \u03b2-Lg\u2212GA complex powders (2.5 mg) were weighed and used for analysis by DSC  with an incremental temperature increase of 10 \u00b0C/min within the range from 20 \u00b0C to 200 \u00b0C. An appropriate amount of \u03b2-Lg, GA or \u03b2-Lg\u2212GA complex solid powders was taken, mixed and grinded with potassium bromide  and spectroscopic  methods. The main characteristic thermal transitions include a glass transition for the amorphous fraction, a melting transition for the crystalline fraction and a transition due to crystallization . The DSC\u22121 was an indicator of amino groups. The peak at 2930 cm\u22121 represented free carboxyl groups with a negative charge. The absorption bands at 1609 cm\u22121 and 1422 cm\u22121 represented asymmetric and symmetric stretching vibration of carboxyl groups. The absorption band at 1066 cm\u22121 represented stretching vibrations of carbonyl groups [The FTIR spectrum of \u03b2-Lg, GA and \u03b2-Lg\u2013GA complexes are shown in l groups .2NH) of \u03b2-Lg showed a weak absorption band at 3293 cm\u22121. The absorption band at 1643 cm\u22121 was believed to be from C=O stretching vibration with minor contributions from the out-of-phase CN stretching vibration, CCN deformation and NH in-plane bend. The region from 1238 to 1393 cm\u22121 was mainly contributed by the NH bending on the side chain structure of \u03b2-Lg [The main signals in the IR spectrum of \u03b2-lactoglobulin may be attributed to the protein backbone. As a globular protein, the secondary amines , which may indicate the electrostatic interactions between amino groups of \u03b2-Lg as a positive group and free carboxylic groups of GA as a negative group. Interestingly, the absorption bands at 1313 cm\u22121 (in \u03b2-Lg), 1066 cm\u22121 (in GA) and 1423 cm\u22121 (in GA), which were present in single \u03b2-Lg or single GA, disappeared in the infrared spectrum of the \u03b2-Lg\u2212GA complexes, which also indicated that the electrostatic interactions between the carboxylic group in GA and NH3+ group on the side chain in \u03b2-Lg were the main forces leading to the formation of the \u03b2-Lg\u2212GA complexes [The band of carboxyl groups in GA and the amino group in \u03b2-Lg shifted after the formation of \u03b2-Lg\u2013GA complexes  will destroy the system, the \u03b2-Lg\u2212GA complexes had good stability at high temperatures, which may be associated with the formation of firm networks between \u03b2-Lg and GA. The electrostatic interactions between the COO"}
+{"text": "Dear Sir,Table 1). It usually complicates the disease course in patients with infections, malignancies and congenital or acquired immunodeficiencies, the latter including patients with SLE.1 Conversely, Childhood Onset SLE (cSLE) is associated with severe pulmonary manifestations, as pleuritis, pulmonary hypertension, acute lupus pneumonitis, chronic interstitial pneumonitis, alveolar hemorrhage, pulmonary embolism and shrinking lung syndrome.3 Due to the rareness of relevant publications in preadolescent patients, we report a diagnostic challenge, a surviving case of a severe pediatric ARDS (pARDS) which was the introductory manifestation of cSLE. The father of the patient described here provided his written consent for publication according to the Declaration of Helsinki. The patient\u2019s management was according to standards of the SLE care.Acute Respiratory Distress Syndrome (ARDS) is a potentially life-threatening emergency within a spectrum of pulmonary diseases characterized by hypoxemia, non-cardiogenic pulmonary edema and a deregulated alveolar hyper-inflammation. The diagnosis-regardless of age-relies on the Berlin Definition criteria , malaise and cough which progressed to a recalcitrant to several anti-infectious regimens pneumonia. She had normocytic anaemia (Hb 9g/dL), proteinuria (urine protein to creatinine ratio [p/cr] 0.67), ESR 67mm/h, CRP 40mg/L  without any pathology of the heart or bone marrow, and sterile biologic samples. Fundoscopy revealed papilledema with retinal haemorrhages and her lumbar puncture, intracranial hypertension. Radiology showed bilateral reticulonodular infiltrates of middle and lower lung lobes , abdominal MRI displayed hepatosplenomegaly with retroperitoneal lymphadenopathy, and her brain MRI was normal.A 5-year intubated girl was transferred to the pediatric intensive care unit (PICU) due to a progressing febrile respiratory failure accompanied by micromacular malar rash, bilateral limb oedema, hepatosplenomegaly and generalized lymphadenopathy. The disease onset was 10-day ago with fever (\u03a4>38.5Table 1), she met all 4 criteria of ARDS: gradual worsening of respiratory symptoms, abnormal chest X-ray with bilateral opacities and respiratory failure with severely impaired oxygenation, with a previous normal echocardiography.1 The bronchoalveolar lavage (BAL) serial work-up did not have any RBCs or findings of diffuse alveolitis in any specimen and cultures were always sterile.She was treated with antibiotics, mechanical ventilation, inotropes and antihypertensives. According to the BDC (3 and prolonged aPTT). Immunology screening revealed IgG 34 g/L , IgA 2.86 g/L , IgM 2.39 g/L  IU/mL , C3 0.14 g/L  and C4 0.02 g/L , high titers of ANA , anti-dsDNA  and positive antiphospholipid antibodies: \u03b22 GPI IgM and IgG .Consecutive blood, urine and gastric fluid cultures remained also sterile. However, her anaemia deteriorated (Hb 7.93g/dL) and coagulopathy emerged  and cyclophosphamide (500mg/m2). Consecutive CTs showed lower lung lobes consolidations and \u201cground glass\u201d opacities , persistent generalized chest and abdominal lymphadenopathy and ascites. Echocardiography revealed left ventricle hypertrophy, pericarditis and mild pulmonary hypertension. Lymph node and bone marrow biopsies were negative for malignancy. After a 4-week care in PICU, the patient gradually stabilized, weaned off the mechanical ventilation and was transferred to the Paediatric Department.According to the paediatric rheumatologist\u2019s assessment, this was a cSLE case which fulfilled both ACR (6/11) and SLICC classification criteria .Her respiratory distress subsided, and she became normotensive. However, renal histology revealed a Class II mesangial proliferative nephritis with IgG, IgA and IgM, C3d, C1q diffuse and moderate granular mesangial depositions, and her renal function was decreased. Eye examination showed persistent vascular twisting indicative of SLE vasculitis. Repeated CTs depicted resolution of pulmonary consolidations, pleural and abdominal effusions, but persistence of the enlarged pulmonary lymphadenopathy and persistent \u201cground glass\u201d appearance. Complement levels remained low (C3 0.55 and C4 0.06 g/L), whereas ANA and anti-DNA titers (1/160 and 1/40), were decreased.Prednisolone, cyclophosphamide, hydroxychloroquine, bronchodilators, antihypertensives and enoxaparin contributed further to her improvement. Anticoagulants were administered due to the presence of anticardiolipins in addition to the long - over a month - intubated stay in PICU. However, she had developed a mild obstructive pulmonary dysfunction and was treated with systemic inhalers, salmeterol plus fluticasone.Six years later, under prednisolone 0.3mg/d, hydroxychloroquine, MMF and Belimumab, she contracted measles from her sibling, as she was unimmunized with MMR. She experienced another, although milder, episode of ARDS, that was successfully treated in PICU with mechanical ventilation, IV antibiotics, inotropes and bronchodilators. At her last evaluation, 6-month later, she had no further respiratory dysfunction and her eyes were free of any sequelae. Due the early disease onset, the possibility of monogenic lupus could not be ruled out, but genetic analysis could not be performed.5 In contrast to previous publications, our case described a very young patient (5-year-old) who rapidly developed severe lupus pneumonitis within a short time of 10 days.7To our knowledge, this is among the first cases of severe pARDS, preceding  cSLE diagnosis.10It projected as a recalcitrant non-cardiogenic, progressively deteriorating pulmonary inflammation. Diagnosis of pARDS was established by revised BDC and of cSLE supported by ACR and SLICC criteria. Several deregulated inflammatory mechanisms triggered by infections, lung trauma or deranged immunity disrupt the alveolar capillary permeability and prevent extravascular oedema resorption. Resolution of ARDS requires the in-situ recruitment of immune \u201canti-inflammatory\u201d cells and restoration of epithelial and endothelial integrity. Future delineation of individual host differences of inflammatory and cell signalling systems will lead to a targeted management of ARDS.10 Other affected sites, as this patient\u2019s retinal vasculitis may rarely accompany the dramatic onset.11 The single most important independent clinical risk factor for mortality in pARDS\u2019 onset is the multiple organ/system dysfunction.10Despite treatment, pARDS (estimated incidence 3.9/100.000 children) has a significant morbidity and mortality. Its severity, management and uneventful outcome are further impaired by immunodeficiencies, as was this cSLE case.12 The rarity of lupus manifestations in young patients aligns with a recent Brazilian publication that included 847 SLE patients. The estimated incidence in patients less than 6 years was 4.6% and underlined the required physician\u2019s vigilance for the existence of SLE in preschoolers.13This particular case highlights that pARDS may be the invading and life-threatening manifestation \u201ccovering\u201d an underlying rheumatic disease and arise with an unexplained and deteriorating alveolar failure. Additionally, the potential risk of recurrent pARDS in case of infections in these partially immunized patients, requires the physician\u2019s vigilance for early and successful diagnosis and management. Noteworthy, the unusual incidence of cSLE onset prior to the age of 6 years, as in the presented patient, may have a genetic background, and research of mutations involved in monogenic lupus will be planned. In conclusion and to our knowledge, this case described the youngest survivor of severe ARDS, with a very short disease onset and a rapidly progressing dramatic pneumonitis that led to the diagnosis of cSLE."}
+{"text": "The electronic health record (EHR) has been fully established in all Norwegian hospitals. Patient-accessible electronic health records (PAEHRs) are available to citizens aged 16 years and older through the national health portal Helsenorge.This study aimed at understanding how patients use PAEHRs. Three research questions were addressed in order to explore (1) characteristics of users, (2) patients\u2019 use of the service, and (3) patient experience with the service.We conducted an online survey of users who had accessed their EHR online at least once through the national health portal. Patients from two of the four health regions in Norway were invited to participate. Quantitative data were supplemented by qualitative information.A total of 1037 respondents participated in the survey, most of whom used the PAEHR regularly  or when necessary . Service utilization was associated with self-reported health, age, gender, education, and health care professional background. Patients found the service useful to look up health information , keep track of their treatment , prepare for a hospital appointment , and share documents with their general practitioner  or family . Most users found it easy to access their EHR online  and did not encounter technical challenges. The vast majority of respondents  understood the content, despite over half of them acknowledging some difficulties with medical terms or phrases. The overall satisfaction with the service was very high . Clinical advantages to the patients included enhanced knowledge of their health condition , easier control over their health status , better self-care , greater empowerment , easier communication with health care providers , and increased security . Patients with complex, long-term or chronic conditions seemed to benefit the most. PAEHRs were described as useful, informative, effective, helpful, easy, practical, and safe.PAEHRs in Norway are becoming a mature service and are perceived as useful by patients. Future studies should include experimental designs focused on specific populations or chronic conditions that are more likely to achieve clinically meaningful benefits. Continuous evaluation programs should be conducted to assess implementation and changes of wide-scale routine services over time. With the rapid rise in the adoption of patient portals, many patients are gaining access to their personal health information online for the first time  and expeAn electronic health record (EHR) is the electronic collection of clinical data and can include clinical assessments, laboratory results, radiology findings, nursing documentation, allergy information, medication information, and discharge letters . PatienteVet pilot program offered by the US Department of Veterans Affairs was an early prototype allowing patients to view and download content of their EHR, including clinical notes, laboratory tests, and imaging reports  has a great value to me as a patient. Now I have a much better picture of my own disease than before. I often have visits with specialists who are not very communicative, and now I have the opportunity to prepare questions\u2014and the best expert on my own illness is myself. Why didn't this service come before?Patients also appreciated the chance to easily read all the information that health personnel wrote about them after attending visits, thus becoming more confident in understanding it, reporting mistakes or misunderstandings, and being better prepared for future visits.I am under psychiatric evaluation. By accessing the health records between visits I can see if the health personnel has misunderstood something I have said. This can be clarified during the next consultation. When the health personnel writes things which have not been discussed yet, I can be better prepared for the next consultation. The service therefore makes the treatment more effective and more appropriate.There were also 23 comments (8.6%) regarding practical benefits of using the service. Patients especially appreciated the convenience of accessing their EHRs directly from home, where they could easily find all their digital documents in one place and read them in a peaceful environment. The remaining comments were related to positive feedback of a more general nature , criticism , or additional information on health status .In the second open text field following the question on whether respondents would recommend using the service to others, a total of 208 comments were expressed, most of which were positive opinions . Online access to EHRs were described as useful, informative, effective, helpful, easy, practical, and safe.I think that this service is especially good when you have old parents or very sick family members who do not get all the information when they are at the doctor or at the hospital. A relative can then get permission to read and try to understand the content and follow up with the treatment . Everything is all gathered here, instead of having papers around your house.Another advantage perceived by the users was that the PAEHR increased accessibility compared with the traditional practice of requesting a copy of their health records on paper or CD. This, in turn, contributed to improved patient engagement.Many are interested in what is written in their health record but just not enough to make them ask to get access to it. Through online access it becomes easier for most people to keep themselves up to date on their own health record, as well as on future appointments.There were 2.4% of respondents (5/208) who expressed mixed comments regarding the utility of the service, which could be more or less beneficial depending on the user characteristics  as well as their health condition. There were only 2.9% of comments (6/208) expressing concerns about online access to EHR, some of which was pointed out by users with a health care professional background.Online access to the health record should not be open to everyone. Now I think first of all about psychiatric patients. I think it can be negative and cause distrust toward health personnel, making them feel like patients and not like persons . Several of the patients I talk with feel unheard and trust much less in the treatment and health care providers than before...Health professionals also express uncertainty and dissatisfaction with open access to health records.Finally, 129 comments were provided in the open-ended question included at the end of the survey where users could write additional thoughts. Four common themes were identified after analyzing the content of these answers: availability of documents, information about their health status, technical issues and suggestions for improvement, and experienced satisfaction. There were 36.4% of comments (47/129) concerning the availability of documents online. Some users missed the chance to access older documents, health records from their GP or other health professionals, documents for their children, laboratory test results, and digital imaging tests. There was also a number of comments about the current lack of documents from the two other health regions which had not yet implemented online access to EHRs. Other respondents reported that they had no or little information visible in their PAEHR. A total of 36.4% of users (47/129) voluntarily provided comments with general information about their health status. There were 13 users who underwent cancer treatment, and 16 users who referred to the presence of chronic illness, such as rheumatologic diseases and other musculoskeletal conditions. Other comments were related to different long-lasting conditions, health problems under treatment, or simply additional information about the number of visits to the hospital. There were 17.8% (23/129) comments specifically reporting issues of a technical nature encountered while using the service. Most comments were related to difficulties in opening specific types of documents and file formats, using a mobile phone, logging in, or accessing specific features. Features which could be improved were the possibility of retrieving the access log, marking documents read and unread, and asking to modify or delete documents. Some respondents also suggested new functions. There were, for instance, four users who expressed their wish for a feature where they could register themselves as blood, organ, or body donors. Finally, 9.3% of comments (12/129) included feedback regarding general satisfaction with the service and its benefits for patients, such as a better understanding of their own health condition. Two users expressed some concerns related to how the communication with health personnel changed after accessing their EHR online.The results obtained from this survey showed that PAEHR in Norway is becoming a mature and useful service. Most of the users accessed their EHR online regularly, for instance when new information became available after a hospital appointment, and read most of the digital documents. The vast majority of the users had at least one doctor's visit in the previous year, meaning that they had digital documents which were recently made available online. There were fewer patients who tried the service for the first time, some of whom did not have any documents accessible. Service utilization for users in Northern Norway was higher than for those in Western Norway, reflecting the earlier implementation of the service in that region.The findings of this study seemed to be aligned with the most recent version of Andersen's behavioral model used to analyze utilization of health care services based on contextual as well as individual determinants of access to medical care . In partMost respondents indicated that the system was easy to use, confirming the positive findings from other studies on patient experience with PAEHRs ,29,42,43Patients using PAEHRs in Norway perceived a number of clinical benefits that were also found in other studies, including enhanced knowledge of their health and improved self-care ,35,42,45With a total of 1037 respondents, this survey is one of the few large-scale studies focusing on patient experience with PAEHRs. We were able to collect a large amount of quantitative data from multiple choice questions and use them to describe the characteristics of the users, patient use of the service, and patient experience with the service. Moreover, quantitative data were used to explore the association between different variables and especially how patient characteristics affected service utilization. However, this was mainly a descriptive survey rather than an explorative study. For a robust investigation of the factors affecting service utilization, a more comprehensive data collection process would be needed. Qualitative information was also collected from three open text fields. A total of 605 comments were analyzed and used to support the quantitative data. Users providing additional comments tend to be those who have very positive or negative experiences. To collect more detailed information on relevant topics, such as patient empowerment, in-depth qualitative interviews with randomly selected users should be conducted in future studies.Despite the number of respondents, one main limitation of this study is related to its design. Although observational studies and surveys have provided evidence of benefits and satisfaction for patients, there is still little reliable evidence of improved health outcomes from experimental studies . Future This was one of the largest surveys conducted on the use of PAEHRs, with respondents from two of the four health regions in Norway. By 2019, online access to EHRs will be offered to citizens in South-Eastern Norway, meaning that an even larger proportion of the population will have access to the service. Patient experience with the service might be influenced by a different level of maturity of the service and therefore vary across regions. For such a wide-scale routine service, whose functionalities might change over time, it is important to implement continuous evaluation programs able to simultaneously evaluate digital health interventions while they are being designed, developed, and deployed . FinallyWe conducted an online survey of users of the PAEHR in Norway. A total of 1037 respondents participated in the survey, most of whom accessed their EHRs online regularly. Service utilization was associated with self-reported health, age, gender, education, and health care professional background. Patients were highly satisfied with the service and found it useful to look up health information, keep track of their treatment, prepare for a hospital appointment, and share documents with their GP or family. Users also experienced clinical benefits from accessing their EHR online, including enhanced knowledge of their health, improved self-care, greater empowerment, easier communication with health care providers, and increased security. Future studies should include both experimental designs focused on specific populations or chronic conditions that are more likely to achieve clinically meaningful benefits and continuous evaluation programs to evaluate implementation and changes of wide-scale routine services over time."}
+{"text": "Knowledge of genomics is an essential component of science for high school student health literacy. However, few high school teachers have received genomics training or any guidance on how to teach the subject to their students. This project explored the impact of a genomics and bioinformatics research pipeline for high school teachers and students using an introduction to genome annotation research as the catalyst. The Western New York-based project had three major components: (1) a summer teacher professional development workshop to introduce genome annotation research, (2) teacher-guided student genome annotation group projects during the school year, (3) with an end of the academic year capstone symposium to showcase student work in a poster session. Both teachers and students performed manual gene annotations using an online annotation toolkit known as Genomics Education National Initiative-Annotation Collaboration Toolkit (GENI-ACT), originally developed for use in a college undergraduate teaching environment. During the school year, students were asked to evaluate the data they had collected, formulate a hypothesis about the correctness of the computer pipeline annotation, and present the data to support their conclusions in poster form at the symposium. Evaluation of the project documented increased content knowledge in basic genomics and bioinformatics as well as increased confidence in using tools and the scientific process using GENI-ACT, thus demonstrating that high school students are capable of using the same tools as scientists to conduct a real-world research task. With the continuing expansion of genomic databases, discovery of rare disease-causing genetic variations and reports of drug efficacy-genotype associations, genomics has ever-increasing relevance to everyday life. It is important that the education of everyone, from doctors to patients, include genomics and bioinformatics for the continued successful integration of genomics into healthcare . At the While a thorough knowledge of genomics is an essential component of science and health literacy required for students to become informed citizens, consumer and professionals, educational resources and curricula fail to address this need, as few high school teachers have received genomics training or any guidance on how to teach the subject to their students . Even feBeginning in 2013 and funded by a 3-years NSF Innovative Technology Experiences for Students and Teachers (ITEST) Grant, we developed the Western New York Genetics in Research Partnership (WNYGRP). The partnership was comprised of the University at Buffalo, including the departments of Biotechnical and Clinical Laboratory Sciences and Family Medicine; the NYS Center of Excellence in Bioinformatics and Life Sciences (CBLS); the New York State Area Health Education Center System (NYSAHEC), including Erie-Niagara (EN AHEC) and Western New York Rural (R-AHEC); Oak Ridge Associated Universities (ORAU); UB faculty with expertise in genome annotation; and a NYS STEM Master High School Teacher. The project introduced high school teachers and students to genomics and bioinformatics through the use of freely available, hands-on, state-of-the-art bioinformatics tools.1. This innovative technology experience increased high school students\u2019 and teachers\u2019 knowledge of bioinformatics and allowed teachers to gain experience with bioinformatics software tools for classroom use through real-world research experiences.This ITEST research project developed partnerships with disadvantaged high schools across a 14-county region in Western New York, forming a pipeline for teacher and student recruitment. The details of the development of the partnership will be presented elsewhere. Grades 9\u201312 biology teachers were trained on the use of the Genomics Education National Initiative-Annotation Collaboration Toolkit (GENI-ACT)The ITEST project had three major components outlined below, consisting of a summer teacher professional development (PD) workshop, teacher-guided student genome annotation projects during the school year, and a capstone symposium at the end of the school year. High school Biology teachers recruited from the targeted schools signed-up for the summer workshop for a variety of reasons, including learning something new, using the training hours to count toward their mandatory staff development, the stipend they received for their involvement, and/or the ability to offer their students something new to add to their portfolios or highlight during college interviews. One teacher commented, \u201cThe idea of exposing students to real science was very enticing to me and I feel like the idea of being a scientist and being able to handle Big Data is a skill that we need to start teaching our students.\u201d Overall, we recruited 74 Biology teachers over the 3 years to take part in the summer professional development training.During the 5-day Summer Workshop, teachers were trained using nine modules customized by project faculty that were based on those in GENI-ACT 9, . After te-values and then allowed to apply it on their own during the week of training. The relative strengths and drawbacks of results obtained from different databases were stressed to inform the development of hypotheses about genes under investigation.Faculty instructors assigned the teachers a set of demonstration genes to annotate that illustrated positive and negative results obtained from the tools in the modules. Teachers were shown how to use each tool and interpret results using such parameters as scores and A manual with background information and complete step-by-step instructions for completing all modules was developed during the project is freely available on our website . The genAs the teachers returned to school in September, they recruited student participants and trained them using the nine GENI-ACT modules. All interested students were offered career counseling and exposure to genomics activities to encourage the recruitment of student participants. Activity 1, College and Career Exploration, was facilitated by AHEC coordinators from the school\u2019s local center, R-AHEC or EN-AHEC, and provided students with STEM college and career guidance. Activity 2, also facilitated by AHEC, explored bioinformatics and genomic careers in more detail. Activity 3, facilitated by University of Buffalo faculty, provided students with an introduction to genome annotation. A total of 1,948 high school students attended at least one of the three activities over the 3 years of the program.Kytococcus sedentarius. The students worked on this gene in the modules, along with a demonstration gene that teachers could use in a \u201cshow one, do one\u201d model of teaching. Most teachers worked with their students through an after school club, as teachers were compensated for their time outside the classroom. Since a randomized design was utilized, the control and intervention students\u2019 work were separated and easier to control outside of the regular classroom in an after school program. On average, teachers met with their intervention students once a week from January through April of the school year. Each teacher worked with a group averaging about seven students, assisting their work on the modules and recording data in their online notebooks. The students enjoyed the GENI-ACT modules. As one student explained \u201cthe modules themselves along with the paper manual really made the program easy to follow, which was great for first time students.\u201d Students also appreciated that each of the genes they were assigned were different and that the modules allowed them find something unique about their particular gene. One student commented that the aspect of the uniquely assigned genes helped to fuel their love of research.To evaluate the effectiveness of the program, informed consent was obtained from all participating students, and pre and post surveys assessed gains of student knowledge and changes related to their attitudes about careers in STEM. An experimental design was used, which randomized the 667 students recruited by the teachers into two groups: 343 were randomized into the intervention group (received GENI-ACT training) and the other 324 into the comparison group (no GENI-ACT training). Comparison group activities included various topics, which included researching bioethics or doing background research on genes identified by the annotators and/or the organism under study. Each student group in the intervention (GENI-ACT trained) was assigned a unique gene from the bacterium Refresher trainings were offered to teachers on three different Saturdays during the school year. The third refresher training, offered in April, dealt with preparing the teachers for their students\u2019 research poster preparation and presentation at the project culminating Capstone Symposium held in May. Using a poster template that could be populated with data generated by their students, teachers submitted the completed posters to program faculty approximately 1 week before the capstone, and faculty edited them for formatting only . The conIn all, four student capstones were hosted. A total of 136 posters were prepared and presented during capstone symposia from 2014 to 2017 and are viewable on our online website . Annual A luncheon also allowed for informal interaction among students, followed by a series of speakers highlighting current topics in bioinformatics and genomics. The capstones concluded with a ceremony recognizing each student and teacher participant with a certificate of participation. Teachers were encouraged to take their posters back to their school and display them in the hallway or classroom. One teacher commented that their students \u201care very proud of those posters hanging up there in the hallway.\u201d Another teacher noted that the capstone is \u201ca nice program for the high school students to see what\u2019s going on at the college level and the poster event is something unique, and something we don\u2019t usually do at the high school level.\u201dF = 37.86, p < 0.001, \u03b72p = 0.55], confirming that teachers increased their content knowledge of bioinformatics and gene annotation by the end of the workshop, as predicted. The content knowledge questions, scoring, and example teacher responses are available in the educational resources section of our project website .Teacher Content Knowledge was measured before and after the workshop. Teachers were asked to complete two sets of 10 True/False questions to assess their knowledge of bioinformatics and genome annotations at the start and end of the summer training workshop. The ten questions included in Set 1 were developed by the Microbial Genome Annotation Network (MGAN) to assess learning in students who used GENI-ACT within their courses. Set 2 includes 10 supplemental items developed by Faculty to help assess learning specific to the program. Mixed ANOVAs produced a significant increase in content knowledge scores from the pre workshop survey to the post workshop survey [t-tests. In the case of every single topic, there was a significant increase by the end of the workshop. The mean increase in confidence from pre workshop to post workshop across all 28 content topics was 56%. The workshops clearly prepared teachers to use the GENI-ACT content and software tools with their students. However, not all teachers went on to work with students during the following academic year, with reasons including perceived difficulty of the project activities, difficulty implementing the study using the control group model or that they personally did not want to participate in the project.Teaching Behaviors around bioinformatics and gene annotation were also expected to increase as a result of training. As a way of gauging their comfort with teaching the material, teachers were asked to rate their confidence in teaching GENI-ACT content topics. Specifically, teachers rated 28 topics on a percentage scale, from 10 to 100% in 10-percentage point increments. Their pre and post workshop ratings were compared using paired t-tests, Intervention students significantly increased their content knowledge of bioinformatics and gene annotation by the end of the project, while comparison students did not, on both Set 1, t(173) = 3.19, p = 0.002 and Set 2, t(173) = 8.40, p < 0.001. Moreover, the scores in the Treatment group increased by well over 50%, especially in Knowledge Set 2.Student content knowledge was projected to increase by the end of program in the intervention group, or those students receiving training on the GENI-ACT modules. Students completed the same content knowledge assessment as the teachers, measured twice as part of pre and post student surveys. Students were asked to complete two sets of 10 True/False questions to assess their knowledge of bioinformatics and genome annotations. In independent Impact of the project could be seen in student participants when it came to college applications, choosing a major and college interviews. One student said that \u201cAfter participating in the ITEST program I knew that I wanted to become a chemical engineer. Furthermore, I knew that I wanted to attend the University at Buffalo because of how research-oriented the university is. Lastly, I knew that I wanted to attempt to pursue applications of chemical engineering in medicine and specifically the genomic medicine field. Over the next 4 years and beyond, I plan to pursue a career in this field.\u201d Another student, who was accepted into RIT after participating in this program, was able to petition to be allowed into a Bioinformatics course that was only available for seniors as an elective. He was able to take the course as a Sophomore because he was able to prove through his Capstone poster that he had all the background knowledge to take the course.Other teacher and student perspectives on performing gene annotations as a part of this project are available in an NSF STEM For All Video Showcase presentation .The results of this project informed different approaches to gene annotation with high school students and teachers that were utilized in another recently completed NIH Science Education Partnership Award (manuscript in preparation). The valuable partnership relationships developed have continued to expand since completion of the ITEST project described here and continue for the foreseeable future through another recently funded project. This project demonstrated that grade 9\u201312 students could grasp gene annotation and bioinformatics tools and use them appropriately.The major limitation of this project for teachers was the use of the control group design. With this design, teachers could not include the gene annotation activities within their regular classes due to the need of having some students in a control group. This restricted most teachers to working with students before or after regular school hours, resulting in competition with other after-school student activities (sports/clubs). Another limitation of the control group design was the amount of time needed to recruit and randomize students before they could begin working with students on their annotations. As such, most teachers could not to begin work with their students until well after winter break and were only able to work through the first four modules before the end of the school year.Sustained use of the bioinformatics tools by teacher participants after project completion is being explored and will be reported in more detail elsewhere. While complete gene annotation is not a common theme, teachers have been able to pick and choose tools from modules to integrate into their curriculum with relative ease. Some teachers have continued to pursue complete gene annotations and have their students present at the annual capstone event tied to another project, as they feel the poster presentation is a great experience for their students. One past participating teacher has integrated all nine GENI-ACT modules into his Honors Biology class by putting together PowerPoint presentations based on the Modules and meeting with the students every day in a lab situation. Future research might aim to determine the effect of taking part in gene annotation on academic performance related to biology and genetics. A study performed at the community college level demonstrated that students taking part in gene annotation in a cell biology lab exhibited clear gains in understanding of topics related to molecular biology in a lecture course , suggestThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the University at Buffalo (IRB). Written informed consent to participate in this study was provided by the participants\u2019 legal guardian/next of kin.SK: training teachers, working with high school students, editing student posters, and writing the manuscript. RD-R: training teachers, working with high school students, and editing student posters. SC-M: program evaluation, writing the manuscript, and supervision of program manager. KK: program evaluation and writing the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest."}
+{"text": "Asbestos-containing pottery shards collected in the northeast of Corsica (Cap Corse) and dating from the 19th century, or earlier, have been analyzed by SEM-EDS, XRPD, FTIR and Raman microspectroscopy. Blue (crocidolite) and white (chrysotile) asbestos fiber bundles are observed in cross-sections. Most of the asbestos is partly or totally dehydroxylated, and some transformation to forsterite is observed to occur, indicative of a firing above 800 \u00b0C. Examination of freshly fractured pieces shows a nonbrittle fracture with fiber pull-out, consistent with a composite material behavior, which makes these ceramics the oldest fiber-reinforced ceramic matrix composite. Residues indicate the use of this pottery as a crucible for gold extraction using cyanide. The amphibole structure is composed of the [Si4O11(OH)]7\u2212 anion . The Raman spectrum of these phases, characterized by a short Si-O-Si bridge between adjacent tetrahedra, shows a well-defined stretching mode varying from 650 to 690 cm\u22121 (see further), or even up to 700 cm\u22121 for jadeite in which aluminum replaces part of the silicon framework.Inosilicates are built with [SiOThe main forms are serpentine, lizardite and chrysotile , which have been used mostly in modern building and automotive applications  due to t3Si4O10(OH)2) results from the degradation of amphiboles and pyroxenes and belongs to the phyllosilicate group, like the serpentinites. XRPD patterns of samples a and b  and quartz in sample c  top. It  a and b  are rathTwo types of raw material sets are recognized, one used for samples a and b and the other used for samples c and d. It should be noted that quantitative analysis of the collected XRPD patterns is not completely reliable due to the preferential orientation of the fibrous phase in relation to the shaping of the pottery.However, it is obvious that the major component in sample a is antigorite; sample b is primarily composed of actinolite and/or tremolite and/or crocidolite , antigorite and chlorite\u2013serpentine; sample c is primarily composed of actinolite and/or tremolite (actinolite and tremolite are difficult to distinguish in complex XRPD patterns like this one); and sample d is primarily composed of actinolite and/or crocidolite (actinolite and crocidolite are hard to distinguish in complex XRPD patterns like this one), antigorite and chlorite\u2013serpentine. Other mineral phases noticed on the XRPD patterns of samples a\u2013d could be treated as moderately abundant.\u22121 peaks corresponding to M-O-Si and Si-O-Si vibrations) [\u22121) are obvious.The spectra show the characteristic signature of serpentinite  . Raman s\u22121 in amosite  to 692 cm\u22121 in chrysotile (white asbestos) [For instance, the Si-O-Si bridge mode shifts from ca. 658 cmsulation ) or 664 sbestos) ,25,26. TChrysotile (white asbestos) consists of long, flexible fibers, the best quality from the point of view considering the fiber\u2019s mechanical properties  and the tolerance of the fiber to folding; the fiber quality of blue and brown asbestos is generally lower, and anthophyllite and tremolite are not really as fibrous as amphibole asbestos . The ide\u22121) is observed in all samples, especially in samples a  is obse\u22121) and chrysotile (3700 cm\u22121). Both phases are identified on the XRPD spectra  only show narrow peaks characteristic of O-H vibrations [\u22121 bands are dominant, which are typical of water adsorbed on porous oxides [The FTIR spectra of asbestos in the O-H and Hbrations . In our s oxides  and of ms oxides . As the \u22121 (f).Ethnological studies  reports \u22121 , with th\u22121 df.\u22121), a very common mineral of a pottery body, is not easily detected by Raman scattering, although it is present as a minor phase in the XRPD (\u22121) is observed in many places by Raman scattering .Surprisingly, the signature of quartz  and then the formation of forsterite at a temperature over ~500 \u00b0C, with the characteristic doublet seen at ~820\u2013850 cm\u22121.Most of the spectra exhibiting a serpentinite-like signature show a rather broad ca. 680 cm\u22121 narrow band, is measured for the c and d samples, and the lowest water content is also found for these samples (measured by the lower intensity of the 3200 cm\u22121 broad band). The 3400 cm\u22121 component may arise from the clay-based matrix [\u22121 band, consistent with a silicate amorphous phase formed in the reaction. Furthermore, for this sample, it was not possible to observe the fiber bundles by optical and scanning electron microscopy, which is most likely due to the higher degree of reaction between phases.Complete de-hydroxylation requires heating above ~700 \u00b0C. Comparison of the IR patterns in d matrix  being mo\u22121) in many places, is consistent with a heating process under reducing conditions; reducing conditions promote the formation of a liquid phase at lower temperatures in iron-rich pottery [Observation of a black core or side for all samples , as well pottery .\u22121, which is characteristic of a CN bond; this can be ascribed to the incorporation of the conservation chemicals  commonly used by archaeologists to preserve the samples. However, cyanoacrylate spectra show a characteristic band at a lower wavenumber, ca. 2250 cm\u22121 [2 (2165 cm\u22121) and is also not far from that of KAg(CN)2 (2141 cm\u22121) [2 and KAg(CN)2 are so-called cyanidation compounds which have been used in gold- and silver-plating/extraction since the 19th century [250 cm\u22121 . The obs41 cm\u22121) ,48,49. K century . The demTwo types of raw materials have been identified in these archaeological asbestos-fiber-reinforced ceramic matrix composites, confirming the ethnological classification. It appears that a selection of the most appropriate asbestos fibers has been made by ancient potters. Obviously, the good mechanical strength due to the fiber reinforcement (the fibrous behavior of the length of the fiber pull-out reaches the millimeter range) was selectively searched for, and at that time the toxicity of asbestos fibers was not recognized. This demonstrates that the use of natural eco-friendly products (clays and stones) and their traditional preparation by women  are not guarantees of the achievement of a good product. Detailed analysis by Raman microscopy of the \u03bdO-H modes shows that the firing conditions were close to or slightly exceeded the degradation temperature of the asbestos fibers, thus preserving their mechanical properties.2 proved the use of one pottery shard as a crucible for gold extraction/separation. This highlights the potential of Raman microscopy, a noninvasive and mobile technique, in identifying residues testifying to nondomestic, chemical and metallurgical uses in the case of these ceramics. A sorting of useful shards for additional analyses can therefore be done on site, in museum reserves or on excavation sites.The observation of traces of KAu(CN)"}
+{"text": "Cosmetics are part of the daily life of the population, and their use can lead to allergic contact dermatitis.To assess the profile of patients diagnosed with allergic contact dermatitis to cosmetics treated at a referral center for 13 years, as well as the characteristics of the clinical picture and allergens involved.This was a retrospective study, with analysis of medical records of patients attended at this service. The individuals included had a diagnostic hypothesis of allergic contact dermatitis to cosmetics and had previously been submitted to epicutaneous tests.A total of 1405 medical records were analyzed, 403 (28.7%) with suspected allergic contact dermatitis to cosmetics and 232 (16.5%) with confirmed diagnosis. Of these, 208 (89.7%) were women, and the age group most affected was 31\u202f\u2212\u202f60 years. The most common locations were face in 195 cases (25.8%), cervical region in 116 (15.3%), and trunk in 96 (12.6%). The main allergens in the contact tests were toluene-sulfonamide-formaldehyde resin in 69 cases (29.7%), paraphenylenediamine in 54 (26.3%), Kathon CG\u00ae in 41 (20.7%), and fragrance-mix 1 in 29 (16.4%). In 154 (66.4%) of the 232 patients with a confirmed diagnosis of allergic contact dermatitis to cosmetics it was possible to specify the cosmetic product responsible for the lesions.The absence of some allergens considered important in the world as causes of allergic contact dermatitis, which are not readily accessible among us.The data of the analyzed population (predominance of young women), as well as the location of the lesions  and the main allergens involved were consistent with those from the world literature. The term \u2018cosmetics\u2019 is defined by the Brazilian National Health Surveillance Agency  as products for external use, intended to protect or beautify different parts of the body. The Food and Drug Administration (FDA) defines them as articles that can be applied to the human body for cleaning, beautifying, highlighting features, changing appearance, or even as components of any of these products, with the exception of soaps.Although the most common adverse effects caused by the use of cosmetics are irritant dermatitis, allergic contact dermatitis (ACD) also occurs, corresponding to about 1% of the reactions. The incidence of ACD varies according to the region, frequency of use of cosmetics, allergenic power of the products used, and access to patch tests (which confirm the diagnosis). The risk factor for its occurrence is the increase in the use of cosmetics; thus, the population most affected is females between 20 and 55 years of age. It is difficult to estimate the frequency of this condition, since most individuals do not seek medical services when experiencing such reactions and discontinue the use on their own.3Hygiene products and moisturizers are the main responsible for the cases of ACD to cosmetics, followed by makeup, hair products, and nail products.ACD to cosmetics occurs at the place of direct application of the product or to which it can be transferred. This transmission can occur through unintentional contact through objects such as towels and phones, through air, and through interpersonal contact.The diagnosis is based on anamnesis, dermatological examination, and patch test. It is important to investigate the products used by the patient, both at home and at work. After diagnosis, it is essential that the patient understands that she/he should avoid contact with the allergen and that the condition may return with new exposures.4The present study aimed to assess the profile of patients diagnosed with ACD to cosmetics treated at a referral center for a period of 13 years, as well as the characteristics of the clinical picture presented and the allergens involved.This was a retrospective study, with analysis of the medical records of patients treated at a reference service outpatient clinic during the period from 2004 to 2017. It was approved by the Human Research Ethics Committee (CAAE 94354218.4.0000.5479).The patients included in the study had a diagnostic hypothesis of ACD to cosmetics and had previously been submitted to epicutaneous tests. According to the anamnesis, the series of allergens used in the tests were: Brazilian standard panel , cosmetics panel , and when possible, cosmetic products that belonged to the patient herself/himself was also included. In all cases, the containers used in the tests were of the Finn Chamber  or Allergo Chamber  type. The tests were applied and read according to the criteria of the International Contact Dermatitis Research Group (ICDRG).In order to standardize the methodology and the reading of the patch tests, avoiding the occurrence of false positives and false negatives, the ICDRG established that the tests must be applied on the high portion of the back of the patients, and the readings must be taken after 48 and 96\u202fh. The reading can show negative or positive results , as shown in Data were collected according to a standard form adopted by the service, in which information such as age, sex, profession, duration of the condition, location of lesions, and results of patch tests are recorded. The collected data was analyzed in an Excel spreadsheet.A total of 1405 medical records were analyzed, among which 403 (28.7%) were suspected of having ACD due to cosmetics and 232 (16.5%) had this diagnosis confirmed. In this group, 208 (89.7%) were female and 24 (10.3%) were male. The referred history period varied from 1 to 528 months, with a mean duration of 32.9 months.The patients' ages ranged from 3 to 88 years; the age group most affected was from 31\u202f\u2212\u202f60 years, with a mean age of 44.4 years.The most common locations were the face in 195 cases (25.8%), the cervical region in 116 (15.3%), and the trunk in 96 (12.6%), as described in Among the 232 patients with ACD to cosmetics, 82 (35.3%) were diagnosed by the cosmetic panel, 65 (28%) by the association of standard panel and extra substances, 55 (23.7%) by the association between cosmetic and standard panel, and 30 (12.9%) by the standard panel.The main allergens with positive results in the patch tests were toluene-sulfonamide-formaldehyde resin in 69 cases (29.7%), paraphenylenediamine in 54 (26.3%), Kathon CG in 41 (20.7%), and fragrance-mix 1 in 29 (16.4%), as shown in In 154 (66.4%) of the 232 patients with a confirmed diagnosis of allergic contact dermatitis by cosmetics it was possible to specify the cosmetic product responsible for the lesions, as shown in Cosmetics are products used daily by a large portion of the population, making them frequent causes of contact dermatitis, both in irritative and allergic forms.The frequency of ACD to cosmetics in the service in the assessed period was 16.5% among patients who underwent patch tests. These rates are equivalent to the data of the groups that study this subject, ranging from 1% to 17.8% of all ACD cases. These figures depend on the location of the study, the frequency of use of cosmetics in the evaluated population, the availability of medical services and, mainly, access to patch tests and allergens that cause dermatitis. The data presented here reflect the frequency of such a diagnosis in a university service with access to patch tests.Regarding gender, the study included 208 women (89.7%) and 24 men (10.3%). This fact is in accordance with literature data, corroborating the idea that the greater number of cosmetics used by women favors the greater frequency of sensitization, although the use of these products has increased among men.5The time of evolution of the dermatosis until the arrival at the service was 44 months, on average, which reflects the poor access of the public service population to patch tests, delaying the diagnosis and implying greater morbidity. Other studies show mean intervals of 23 and 29 months.The two regions of the body most affected were the face and neck, coinciding with the areas of greatest contact with cosmetics, both by direct application and by indirect contact.ACD to cosmetics can be caused by different components of the formulations, such as active ingredients, preservatives, fragrances, emulsifiers, and vehicle components.Among the active principles, toluene-sulfonamide-formaldehyde resin (R-TSF) was the most common among all allergens surveyed in the sample (29.7%). These cases were exclusively diagnosed among women. This resin is present in nail enamels, allowing for durability after application. It is an allergen still prevalent in Brazil, although fewer cases have been observed in the present service.Paraphenylenediamine (PPDA), present in permanent and semi-permanent hair dyes, was the second most frequent among women and men. Although the scalp is thick, this allergen is capable of causing reactions that are often intense and severe. Lesions can also occur on the face, eyebrows, neck, and ears, without affecting the scalp. In addition, this allergen is commonly included in impure henna tattoos, causing sensitization in children.Ammonium thioglycolate, a reducing agent used in hair straightening and perming products, is widely used in Brazil, especially in procedures performed in the domestic environment. It accounted for 3% of cases of ACD to cosmetics. It is an uncommon allergen, but in 2017 a Japanese study showed 4.8% of patients with reactions to products applied to hair that were positive to this agent.Preservatives had a significant number of reactions, and isothiazolinones were the most frequent. Kathon CG\u00ae (methylisothiazolinone\u202f+\u202fmethylchloroisothiazolinone) accounted for 20.7% of positive tests. It is a common preservative in water-based products, such as creams, lotions, shampoos, and baby wipes. It can also be found in products for industrial use, such as wall paints, cutting oils, glues, textiles, and leather. Contact dermatitis induced by this preservative mainly affects the face and hands in adults. In children, the most affected regions are the perioral and genital regions, and the buttocks, due to their presence in wet wipes.Unpublished data from this service indicate a 17% frequency of sensitization to Kathon CG\u00ae in the general population. This frequency was higher in the present study, as it included a specific group of ACD by cosmetics . The frequency of sensitization increased substantially from 2011 onwards in the United States and Europe; in Brazil, Scherrer and Rocha demonstrated an increase in sensitization from 3.35% to 11.14% between 2006 and 2012.e.g., shampoos and soaps) and topical medicines. Due to their allergenic and carcinogenic potential, formaldehyde-releasing preservatives can be used instead. In the current study, 8.2% of the cases presented sensitization to formaldehyde, some related to the use of hair straightening products. Although prohibited by the ANVISA as a straightener, it is still used in informal settings, at unknown concentrations. The frequencies of sensitization to formaldehyde range from 2% to 3% in Europe and from 8% to 9% in the United States; therefore, the frequency observed in the present study is similar to the one observed in the United States. The frequency of sensitization to formaldehyde-releasing agents such as quaternium-15 (2.6%), bronopol (1.7%), and imidazolidinyl urea (0.9%) was low.Formaldehyde is a well-known antiseptic used as a preservative in cleaning products, cosmetics  accounted for 3% of positive tests, a higher frequency than that of the literature (below 1%). This product is used as a preservative in personal care and sports products, bedding, and toys.Other preservatives, such as BHT (antioxidant), chloroacetamide, sorbic acid, and chlorhexidine, presented low frequencies, and were considered uncommon causes of ACD.Fragrances are among the most common allergens in cosmetics and, in this study, accounted for 16.4% of positive tests. This value was lower than that observed in the literature, where these substances account for 30% to 40% of cases of allergy to cosmetics. Fragrance-mix 1, balsam of Peru, and colophony are considered as markers of ACD to fragrance in Brazil.Among the mixes, only the fragrance-mix 1  was analyzed in the current study, a fact that could reduce the diagnosis of ACD by fragrances by 15% to 33% when compared with foreign studies, in which fragrance-mix 2 is routinely used in patch tests.Balsam of Peru is a natural resin composed of more than 250 different chemical substances and is used as a fragrance fixator. In the present study, the frequency of sensitization to this substance was 6% and was related to cases of sensitization to fragrances in six cases (43%), while the other eight had isolated positivity. It is estimated that at least 50% of cases of allergy to fragrances have positive reactions to balsam of Peru, as observed in the present study.Colophony is a plant-based resin composed of a complex mixture of acidic (90%) and neutral (10%) resins. The abietic and dehydroabietic acids are the most important, and the allergens are products of their oxidation. This resin has multiple uses; its use in perfumes is uncertain, but cross-reactions between substances are well described. In the studied group, 18 patients (7.7%) were sensitive to it, and in 17 cases (7.3%) there was concurrent reaction with fragrance-mix 1. A study by the same group that studied fragrance sensitization, published in 2018, showed 10% of concurrent positive tests.The products used as vehicles in cosmetics were responsible for nine cases of ACD (2.8%). Among these, lanolin (1.7%) and Amerchol L-101 (1.3%) are noteworthy. The former is extracted from sheep\u2019s wool and widely used in cosmetics and topical medicines. The latter is a commercial product that contains lanolin alcohols obtained from its hydrolysis. Although both are frequently implicated in the ACD of patients with ulcers of the lower limbs and, more recently in patients with atopic dermatitis, they also appear as allergens to cosmetics, as demonstrated in the present study.Propylene glycol is a synthetic alcohol that can be used as an emollient, solvent, preservative and emulsifier, being found in various products such as cosmetics, personal care products, medicines (including corticosteroids), food, and recently in electronic cigarettes. In this study, test positivity was observed in 1.3% of patients; this finding is in agreement with the literature, where the frequency varies between 0.8% and 3.5% of cases.Another positive allergen in the tests was triethanolamine, an emulsifier used in cosmetics and topical medications, positive in 2.1% of cases, a value below that observed by Silva et al. in a 2012 publication.In the present study, it was possible to identify the products that were responsible for the condition in 66.4% of patients diagnosed with ACD to cosmetics . In thesNail polishes were the most common, followed by hair dyes, perfumes, shampoos and other hair products, body moisturizers, deodorants, sunscreens, soaps, and hair straightening products, popularly known as progressive hair brush. The culprit cosmetics vary according to consumption habits, hygiene habits, and cultural and religious traditions. A study carried out in India with patients presenting ACD to cosmetics has indicated face creams, hair dyes, and soaps as the most common. In Brazil, painting nails is a common habit among women, making enamels common ACD agents.A limitation of the present study was the inclusion of only allergens from standard Brazilian and cosmetic panels, although it is known that there are still other sensitizers frequently found in cosmetics. Currently, there are extended panels, which allow testing of a wider range of substances ; however, as they were not available in this service during most of the analysis period, they were not included in the study.The frequency of ACD for cosmetics was 16.5% among patients who underwent patch tests. The analyzed population was predominantly female, whose age ranged from 31 to 60 years, with involvement of the face and cervical region; these findings are in agreement with the literature data. The main allergens involved were toluene-sulfonamide-formaldehyde resin, paraphenylenediamine, Kathon CG\u00ae, and fragrance-mix 1. However, the study had some limitations, such as the absence of some allergens for analysis, which are currently considered important worldwide as causing ACD, and whose access is still restricted in this setting. Even in the absence of these allergens, it was possible to draw a profile of the cosmetics that cause ACD in a sample of the Brazilian population.None declared.Mariana de Figueiredo Silva Hafner: Approval of the final version of the manuscript; conception and planning of the study; effective participation in research orientation.Ana Carolina Rodrigues: Obtaining, analyzing, and interpreting the data.Rosana Lazzarini: Conception and planning of the study; elaboration and writing of the manuscript; critical review of the literature.None declared."}
+{"text": "A form of pathological social withdrawal which is also called hikikomori has been proved its existence in China. But the prevalence and characteristics of hikikomori in China remain unknown. Past studies had investigated the hikikomori phenomenon in three cities of China. The purpose of this study is to discover the prevalence of hikikomori in a convenient online sample in China as well as the difference in demographic characteristics and other possible traits between hikikomori sufferers and the general population.A total of 1,066 youths (mean age = 22.85 years) in China completed the online questionnaire, which consisted of questions about demographics, the 25-item Hikikomori Questionnaire (HQ-25), the Internet Addiction Test (IAT), the Loneliness Scale (UCLA), and the General Health Questionnaire (GHQ). SPSS is used to evaluate the data.2 = 38.658, P = 0.000), the Hosmer-Lemeshow test value is 7.114 and P = 0.524 > 0.05.Of the 1,066 youths, 980 (91.9%) were identified as belonging to group A , 46 (4.3%) to group B , and 40 (3.8%) to group C . The hikikomori group (combined group B and group C) accounted for 8.1%. The present data suggest that residence and loneliness are related to the occurrence of hikikomori. HQ-25 score of the hikikomori group was significantly higher than the comparison group. The UCLA score showed that those in the hikikomori group felt lonelier than those in the comparison. The regression model predicted hikikomori risk (\u03c7The grouping criterion in our present study is reasonable and such a grouping criterion can screen out potential populations of hikikomori. When people develop into hikikomori sufferers in the present, their social withdrawal behaviors and feeling of loneliness are both much more severe than in the past. The possible relationships between hikikomori and loneliness reflect the need to give the youths more social support, to help them connect with society. Social withdrawal syndrome was first described in Japan as hikikomori and defined as the state of confining oneself to one's home for more than 6 months and strictly limiting communication with others , and occupational and educational disengagement , among these participants who completed the survey, 13 (9.5%) were identified as belonging to the withdrawal group, 7 (5.1%) to the asocial group, and 9 (6.6%) to the hikikomori group  , to group B , and to group C .A total of 1,066 valid online questionnaires were collected. The sample comprised 390 males (36.59%) and 676 females (63.41%), Participants took part in an online survey launched on WeChat. The specific approach was: to contact the counselors of universities and colleges to send the questionnaire weblink into the WeChat group which teachers and students all in. The range of the questionnaire included all around China, thanks to the help of teachers in colleges and universities. Participants who were interested could access the study online and take part in the study. Also, students can share the weblink with friends they think may be interested in the hikikomori study, or people who may be hikikomori sufferers. Those who agreed to participate answered a range of questions about their social life and their experiences with social withdrawal. All questionnaires that were answered completely and sufficiently were included in the study.The informed consent form explicitly indicated that participation was voluntary, that respondents were free to withdraw from the study at any time, that if at any point respondents chose to discontinue participation, they were not required to provide any explanation, and there was no penalty associated with withdrawing. Respondents were only able to complete and submit the questionnaire once consent to participate in the study was provided, and they indicated that they understood the nature of the research being conducted.Online assessments are reliable and valid methods and they can facilitate the study. A correlational study of socioeconomic factors and the prevalence of hikikomori in Japan from 2010 to 2019 had conducted online assessments and found the incidence of hikikomori  are 93.48 and 90.74% . This study used a modified version of the definition of hikikomori proposed before  was developed as a self-administered instrument for assessing the severity of symptoms of hikikomori  which has 20 items regarding internet overuse. All items begin with the phrase \u201cHow often do you\u2026\u201d, e.g., \u201cHow often do you try to cut down the amount of time you spend online and fail?\u201d Respondents are requested to choose one of the following scores: 5 = always, 4 = often, 3 = frequently, 2 = occasionally, and 1 = rarely. The IAT has been used to measure the severity of internet addiction. The total score of IAT ranges from 20 to 100. The Cronbach's alpha of the Chinese version scale was 0.930, the reliability of the Chinese version scale was 0.940 . GHQ-12 is a popularly used screening self-report for emotional disorders among adults. It includes 6 positive items and 6 negative items. The total score of GHQ-12 ranges from 0 to 36, higher total scores reflect higher levels of psychological morbidity or distress, a lower score means better mental status. Participants whose scores are lower than 13 are at good mental status. The Cronbach's alpha of the Chinese version scale was 0.830, the reliability of the Chinese version scale was 0.608 . The frequencies and means of the demographic variables of the study were first calculated by descriptive statistics. Data were presented as means \u00b1 standard deviations.post-hoc test.The differences between demographic variables and hikikomori prevalence among the three groups were analyzed by ANOVAs and chi-squared tests. The results of multiple comparisons were presented when there was a significant statistical difference within the three groups. Bonferroni was used to conduct the In total, 1,066 participants completed the survey, among whom 980 (91.9%) were identified as belonging to group A (be not isolation nor withdrawn), 46 (4.3%) to the group B , and 40 (3.8%) to group C .F = 5.231, P = 0.005). This indicates that such a grouping criterion is reasonable and such a grouping criterion can screen out potential populations of hikikomori. Those three groups were significantly different in gender , residence , and educational level   see .t-test, participants from single-parent families had significantly higher HQ-25 scores than those core families . Participants with a diagnosis of mental disorders had significantly higher HQ-25 scores than those with no mental disorder diagnosis . There was a significant difference in the education level in the HQ-25 scale score , the score of the below undergraduate group is higher than undergraduate  and master's degrees and above group . There was no significant difference in HQ-25 scores between males and females , between registration of urban and rural , between the only child and the not-only child .Using Using the chi-square test, the results showed that the three groups had significant correlations with gender, residence, educational level, and diagnosis of mental disorders. There was no significant correlation with registration, economic sources, monthly income, and whether they were the only child.t = 2.737, P = 0.006), UCLA score , IAT score . There were significant differences between group A and group C in the UCLA score .There were significant differences between group A and group B in HQ-25 score , the score of group B is significantly higher than group A , the score of group C is higher but not significantly than group A . There were no significant differences between group B and group C's HQ-25 , UCLA score , IAT score , GHQ score  (see There were significant differences in HQ-25 scores among the three groups (524) see .N = 86, 8.1%): marked with a duration of at least 3 months, or both social isolation in one's home and withdrawn. Using group A as the comparison group . The prevalence in our present research is 8.1%. The score of hikikomori group is significantly higher than comparison group in HQ-25 , UCLA score , IAT score .Group B and group C were combined into the hikikomori group , UCLA , IAT , and GHQ  among the group \u201cnever,\u201d \u201cpast,\u201d and \u201cnow\u201d. Group \u201cnow\u201d are significantly higher than group \u201cnever\u201d in the score of HQ-25 , UCLA , IAT , there is no significant difference in the score of GHQ  between \u201cnow\u201d and \u201cnever\u201d group. Group \u201cnow\u201d are significantly higher than group \u201cpast\u201d in the score of HQ-25 , UCLA , there are no significant differences in the score of IAT , GHQ  between \u201cpast\u201d and \u201cnow\u201d group.According to the answer of three questions, we compare these three groups in which answer is \u201cnever,\u201d \u201cpast,\u201d and \u201cnow\u201d, there are significant differences in the score of HQ-25 , UCLA , IAT  and GHQ  between these two groups.According to the duration of social withdrawal, we compare two groups' people whose duration of social withdrawal is 3\u20136 months and above 6 months, there is no significant difference in the score of HQ-25  in gender, registration, residence, family structure, whether they were the only child, educational level, and monthly income and expenses, see 2 = 38.658, P = 0.000). The Hosmer-Lemeshow test value is 7.114 and P = 0.524 > 0.05, indicating that the regression model is well adapted. The Cox-Snell correlation strength value is 0.036 and the Nagelkerke value is 0.083. Among them, the Wald values of \u201cgender,\u201d \u201cresidence,\u201d \u201conly child,\u201d \u201cfamily structure,\u201d \u201ceducational level,\u201d \u201cdiagnosis of mental disorders,\u201d \u201cage,\u201d \u201cloneliness,\u201d \u201cinternet addiction,\u201d and \u201cmental health condition\u201d were 0.947 (P = 0.331), 1.763 (P = 0.184), 0.502 (P = 0.479), 0.715 (P = 0.870), 2.234 (P = 0.327), 0.469 (P = 0.494), 0.009 (P = 0.924), 4.807 (P = 0.028), 0.623 (P = 0.430), and 3.697 (P = 0.055), respectively  were identified as belonging to group A (be not isolation nor withdrawn), 46 (4.3%) to the group B , and 40 (3.8%) to group C . The hikikomori group (combined group B and group C) accounted for 8.1%. The prevalence in our present research is kind of consistent with past research in three urban areas of China , in which 13 (9.5%) were identified as belonging to the withdrawal group, 7 (5.1%) to the asocial group, and 9 (6.6%) to the hikikomori group   between 3 to 6 months and above 6 months. There are no significant differences in gender, registration, residence, family structure, whether they were the only child, educational level, and monthly income and expenses. Consistent with the previous studies . This again indicated that such a grouping criterion is reasonable and such a grouping criterion can screen out potential populations of hikikomori. The score of HQ-25 can also help in identifying social withdrawal sufferers, we suggest that a score of 40 can be used as a critical value.Utilizing this reasonable grouping criterion, we investigated the prevalence of hikikomori in a convenience online sample in China. In our present research, the score of HQ-25 showed significant differences between group A (HQ-25 score = 32.61 \u00b1 17.912), group B (HQ-25 score = 40.11 \u00b1 22.796), and group C (HQ-25 score = 38.05 \u00b1 19.683). Specifically, group A is significantly lower than group B and group C in the HQ-25 score. The score of the hikikomori group (HQ-25 score =39.15 \u00b1 21.306) is significantly higher than the comparison (HQ-25 score =32.61 \u00b1 17.912) group in HQ-25 selection bias took place. In fact, both the level of social status, the economic income, and the state of work may be related to social withdrawal. We suggest investigating people of all walks of life in the future. In addition to social status, economic income, and the state of work, age is also a factor worth expanding. The Cabinet Office announced that the estimated number of hikikomori aged between 40 and 65 years is 610,000 in Japan, including individuals over the age of 40 years would increase the number of hikikomori sufferers even further , UCLA , which indicate that social withdrawal in the past can develop into hikikomori sufferers to some degree. When people develop into hikikomori sufferers in the present, their social withdrawal behaviors and feeling of loneliness are both much more severe than in the past.Our results do show a mixed picture of psychiatric and social factors for severe social withdrawal. The results on one hand indicate that there are increased negative behaviors and higher GHQ-12 scores for social withdrawal individuals, which are proxy correlates of psychiatric concerns. On the other hand, only 5.9% had mental disorders history in the past. These findings are inconsistent with the work carried out in Japan indicating that around 54.5% had experienced a lifetime psychiatric disorder , Health Law Research Association Program of Shanghai Law Society (grant number: 2020WF03), Shanghai Clinical Research Center for Mental Health (grant number: 19MC1911100), and Excellent Talent Training Program of Three Year Action Plan on Public Health of Shanghai (2020-2022) (grant number: GWV-10.2-XD27).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher."}
+{"text": "Alterations in the canonical processing of Amyloid Precursor Protein generate proteoforms that contribute to the onset of Alzheimer\u2019s Disease. Modified composition of \u03b3-secretase or mutations in its subunits has been directly linked to altered generation of Amyloid beta. Despite biochemical evidence about the role of \u03b3-secretase in the generation of APP, the molecular origin of how spatial heterogeneity in the generation of proteoforms arises is not well understood. Here, we evaluated the localization of Nicastrin, a \u03b3-secretase subunit, at nanometer sized functional zones of the synapse. With the help of super resolution microscopy, we confirm that Nicastrin is organized into nanodomains of high molecular density within an excitatory synapse. A similar nanoorganization was also observed for APP and the catalytic subunit of \u03b3-secretase, Presenilin 1, that were discretely associated with Nicastrin nanodomains. Though Nicastrin is a functional subunit of \u03b3-secretase, the Nicastrin and Presenilin1 nanodomains were either colocalized or localized independent of each other. The Nicastrin and Presenilin domains highlight a potential independent regulation of these molecules different from their canonical secretase function. The collisions between secretases and substrate molecules decide the probability and rate of product formation for transmembrane proteolysis. Our observations of secretase nanodomains indicate a spatial difference in the confinement of substrate and secretases, affecting the local probability of product formation by increasing their molecular availability, resulting in differential generation of proteoforms even within single synapses.The online version contains supplementary material available at 10.1186/s13041-021-00855-x. The APPThe spatial proximity of \u03b3-secretase to its substrate either by local confinement within nanodomains or by random diffusional collisions on the plasma membrane is a requisite for generation of different proteoforms \u201315. Due NCT/pre, nanodomainNCT/post and nanodomainNCT/peri indicate NCT nanodomains in regions marked positive for CAZ/PSD/EZ functional zones of the synapse , a postsynaptic marker for postsynaptic density (PSD) and a perisynaptic marker for the endocytic zone (EZ). The distribution profile of NCT within different functional zones of the synapse was assessed by multi-colour ensemble-based super resolution imaging using Stimulated Emission Depletion microscopy (STED) and Airyscan super resolution microscopy Fig.\u00a0: Fig.S1.NCT/post was significantly lower compared to both nanodomainNCT/pre and nanodomainNCT/peri. On the other hand, the length of nanodomainNCT/pre was similar to that of nanodomainNCT/peri  and pre-synaptic markers (Bassoon\u00a0and Piccolo). B, D Indicate the pseudocolour coded\u00a0distribution of Nicastrin and overlay with corresponding markers for functional\u00a0zones of the synapse. The pseudocolour overlay of Nicastrin (green) with the\u00a0postsynaptic marker Shank2 in red and the presynaptic marker Bassoon in blue is\u00a0shown in B. The pseudocolour\u00a0overlay of Nicastrin (green) with the postsynaptic marker PSD95 in red and the\u00a0presynaptic marker Piccolo in blue is shown in D. E Magnified view of\u00a0the boxed regions from pseudocolour overlay in B and D. Scale bar in\u00a0B, D indicate 15\u2009\u03bcm and in E\u00a02\u2009\u03bcm. F Represents line scans\u00a0connecting the centroids of pre- and post-synaptic reference molecules, indicating\u00a0the distribution of Nicastrin with Shank2, Bassoon and PSD95, Piccolo. The X-and Y-axis represent the length (\u03bcm) and normalized intensity (a.u.)\u00a0respectively. Figure S2.Quantification of\u00a0the nanoscale architecture of Nicastrin clusters within different functional\u00a0zones of a synapse and on neuronal processes using STED microscopy. A, B Diversity in Nicastrin\u00a0 clusters with respect to nanodomain length A and\u00a0intensity B\u00a0in pre/post/perisynapse. Significance was determined by Kruskal-Wallis\u00a0test followed by Dunn\u2019s multiple comparison\u00a0test. Indications of significance correspond to P values *P\u2009\u2264\u20090.05, **P\u2009\u2264\u20090.01,and ***P\u2009\u2264\u20090.001, ns P\u2009>\u20090.05. n\u2009=\u20095155 (pre), 3016 (post) and 3966 (peri)\u00a0puncta from 3-4 biological repeats. C, D Indicate the nanoscale architecture\u00a0of Nicastrin clusters on the neuronal processes. The distribution of the length\u00a0of Nicastrin nanodomains is shown in C\u00a0and the intensity in D. n\u2009=\u20093521nanodomains from 3-4 biological repeats. Figure S3.Distribution of Nicastrin in inhibitory neurons and within inhibitory\u00a0synapses of pyramidal neurons using confocal microscopy. A\u00a0Evaluation\u00a0of the presence of Nicastrin in Parvalbumin expressing GABAergic inhibitory\u00a0neurons. The pseudocolour overlay represents Nicastrin in green and parvalbuminin red. The white arrows indicate the presence of both Nicastrin and\u00a0parvalbumin, while the red arrows indicate the presence of Nicastrin in the absence\u00a0of parvalbumin. Scale bar in A\u00a0indicate 28\u2009\u03bcm (upper panel) and 11\u2009\u03bcm (lowerpanel). B\u00a0Evaluation of the presence of Nicastrin in Parvalbumin/Calbindin\u00a0expressing GABAergic inhibitory neurons. The pseudocolour overlay represents\u00a0Nicastrin in green, parvalbumin in red and Calbindin in blue. Scale bar in B indicate 18\u2009\u03bcm. C\u00a0Indicate the distribution of Nicastrin within inhibitory\u00a0synapses of pyramidal neurons. The pseudocolour overlay indicates Nicastrin ingreen and Gephyrin, a marker for the inhibitory postsynapses in magenta. The\u00a0blue arrows indicate the clusters of Nicastrin overlapping with Gephyrin, while\u00a0the yellow arrows indicate their independent distribution. Scale bar in C\u00a0indicate 11\u2009\u03bcm (left) and 2\u2009\u03bcm . Figure S4.Discrete nanoscale association of\u00a0Nicastrin with PS1 and APP on neuronal processes using STED microscopy. A\u00a0STED image of Nicastrin (magenta) with pseudocolour overlay of PS1\u00a0(green).  are magnifiedinsets of regions indicated in A. B STED image of Nicastrin (magenta) withpseudocolour overlay of APP (green).  are magnified insets of regions\u00a0indicated in B. Scale bar in A, B\u00a0indicates 3\u2009\u03bcm (left) and 750\u2009nm (right).The black contours represent segmented regions marking the continuous stretc.hof neuronal processes, marking the presence of Nicastrin. Figure S5.Quantification of the nanoscale\u00a0architecture of Nicastrin clusters associating with PS1 and APP on neuronal\u00a0processes using STED microscopy. A, B Indicate the distribution of the\u00a0length A\u00a0and intensity B\u00a0of Nicastrin nanodomains with PS1 and APP. C, D\u00a0Diversity in nanodomain length C\u00a0and intensity D\u00a0of Nicastrin clusters  associating with PS1 and APP. Significance was determined by unpaired two-tailed Mann-Whitney test. E, F\u00a0Comparison of RSP E and RSE F for quantifying colocalization of Nicastrin with respect to PS1 and\u00a0APP. The data are represented as mean \u00b1 SEM.\u00a0Significance was determined by two-tailed unpaired Student\u2019s t-test with\u00a0Welch\u2019s correction. Indications of significance correspond to P values *P \u22640.05, **P\u2009\u2264\u20090.01, and ***P\u2009\u2264\u20090.001, ns P\u2009>\u20090.05. n\u2009=\u20095417 (Nicastrin on PS1) and 7163 (Nicastrinon APP) puncta from 3-4 biological repeats. Figure S6.Identification of synapse associated endocytic zone. A,\u00a0B The workflow to detect synapse associated Dynamin (endocytic zones)\u00a0using a combination of both super resolution (STED) and conventional \u00a0imaging paradigms. A\u00a0The confocal image of PSD marker\u00a0and STED image of Dynamin were selected and thresholded to detect regions with\u00a0high molecular content. They were then size filtered and obtained regions were\u00a0converted into binary images. B The overlay of the masks confirms the overlap\u00a0of segmented clusters of Dynamin with PSD. The automated evaluation of synaptic\u00a0masks in the Dynamin positive domains was performed. Absence of Dynamin in PSD\u00a0positive regions (green regions) were considered as negative, presence of both markers\u00a0as positive (red regions) and dynamin alone as false positive (magenta\u00a0regions). The paradigm involves sequential segmentation protocols to isolate\u00a0Dynamin that is associated with the synaptic compartments and marking these\u00a0segmented regions as synaptic endocytic zones. Scale bar in A, B\u00a0indicate 5\u2009\u03bcm.  associated with Dynamin\u00a0(Magenta) obtained using STED microscopy. B\u00a0The workflow on super resolution\u00a0images (STED) to detect Dynamin clusters colocalized with Clathrin,\u00a0another marker for endocytic zone. The STED image of endocytic markers namely, Clathrin\u00a0and Dynamin were selected and thresholded to detect regions with high molecular\u00a0content. They were then size filtered and obtained regions were converted into\u00a0binary images. The overlay of the masks confirms overlap of segmented clusters\u00a0of Clathrin with Dynamin. Automated evaluation of Clathrin in the Dynamin\u00a0positive domains was performed. For this purpose, the automatically detected\u00a0Dynamin positive regions were transferred to the binary masks positive for\u00a0Clathrin. Absence of Clathrin signal in Dynamin positive region was considered\u00a0as negative, and those regions were not considered as endocytic regions. This\u00a0segmentation protocol selectively evaluates domains enriched in both Clathrin and\u00a0Dynamin, and therefore the presence of functional endocytic machinery. Scale bar in A\u00a0indicate 5\u2009\u03bcm\u00a0and in B\u00a02.25\u2009\u03bcm.\u00a0(Please Refer to Supplementary information (Additional file"}
+{"text": "This randomized trial evaluates whether individually addressed emails designed with behaviorally informed features increase COVID-19 vaccination rates. After 1 large Pennsylvania health system sent 36 vaccine-related mass emails to employees over 5 weeks (eAppendix in CONSORT) reporting guideline. The Geisinger institutional review board determined that this health care operations project did not constitute human participants research and that a follow-up research analysis was exempt from review or the requirement for informed consent under 45 CFR \u00a746.104(d)(4)(iii). The trial protocol is available in This project followed the Consolidated Standards of Reporting Trials  or by favorably juxtaposing the vaccine\u2019s risks with those of COVID-19, ie, reframing risks3 . Both emails asked employees to make an active choice4 to receive a vaccine  or not (hyperlinked to a survey soliciting their primary reason for declining). Employees in the delayed condition were randomly assigned to receive 1 of these emails  3 days later. The primary outcome was registration on the vaccination scheduling portal during the 3 days after the first emails were sent.In this randomized trial, we assigned 9723 employees  and logistic regression analyses were conducted using R version 4.0.2 . For all analyses, odds ratios (ORs) from logistic regressions were calculated, along with asymptotic 95% CIs; 2-tailed P\u2009<\u2009.001; reframing risks: percentage of participants registering, 6.90%; 95% CI, 6.07%-7.83%; OR, 2.26; 95% CI, 1.77-2.87; P\u2009<\u2009.001) (P\u2009=\u2009.50). Among the 1229 HCWs who declined to register and then completed the survey, the most common reasons were unknown vaccine risks (430 [35%]) and pregnancy-related concerns (165 [13%])  women and 21\u2009168 (89%) White employees, with a mean age of 43 years. Of the 9723 targeted employees, 9457 (97%) had valid email addresses. Both emails  led to more registrations in the first 3 days than the delayed condition  . There w5 [13%]) .During the 3-day study period, an individual email nudge caused more than twice as many HCWs to register for a COVID-19 vaccination compared with HCWs in the control condition, with no significant difference between the 2 emails. A limitation of this trial is that due to the imminent closure of employee-only vaccination clinics, we could only delay the intervention in the control group by 3 days. Moreover, by choosing to compare 2 behaviorally informed emails, we are unable to exclude the possibility that a plain reminder might have had the same effect. Furthermore, we could not measure actual vaccination, as appointment slots were unexpectedly unavailable for many who registered for one.5 The emails\u2019 behavioral features\u2014active choice, appeal to authority, and emphases on scarcity, social norms, and risk recalibration (eAppendix in 6 and may be greater among recipients who are less hesitant about receiving the vaccine. Sending targeted emails, patient portal messages, or text messages designed with behavioral science is inexpensive, scalable, and easily implemented and could be an effective way to encourage vaccination by HCWs and the general public.Given the large volume of previous COVID-19 vaccine promotion to HCWs, it may seem counterintuitive that a single additional reminder could increase vaccination by late adopters. However, competing demands on attention, behavioral inertia, and unwieldy processes that make it hard to follow through on intentions likely conspire to make a single, timely, targeted reminder helpful."}
+{"text": "Despite the availability of vaccines, invasive bacterial diseases remain a public health concern and cause childhood morbidity and mortality. We investigated the characteristics of etiological agents causing bacterial meningitis in children <5 years in the years pre- (2010\u20132012) and post- (2014\u20132019) 10-valent pneumococcal conjugate vaccine (PCV10) introduction in Zambia.Streptococcus pneumoniae (Spn), Haemophilus influenzae (Hi), and Neisseria meningitidis (Nm) from cerebrospinal fluid (CSF) were identified by microbiological culture and/or real-time polymerase chain reaction.pneumoniae, Hi, and Nm accounted for 67% (148 of 221), 14% (31 of 221), and 19% (42 of 221) of confirmed cases, respectively. Thirty-six percent of pneumococcal meningitis was caused by 10-valent pneumococcal conjugate vaccine (PCV10) serotypes, 16% 13-valent pneumococcal conjugate vaccine and 39% by nonvaccine serotype (NVS). There was an association between the introduction of PCV10 vaccination and a decrease in both Spn meningitis and the proportion of PVC10 serotypes in the postvaccination period. Antimicrobial susceptibility of 47 Spn isolates revealed 34% (16 of 47) penicillin resistance. The 31 serotyped Hi accounted for 74% type b (Hib) and 10% type a (Hia). All 42 serogrouped Nm belonged to serogroup W.During the surveillance period, a total of 3811 children were admitted with suspected meningitis, 16% (598 of 3811) of which were probable cases. Bacterial meningitis was confirmed in 37% (221 of 598) of the probable cases. Spn There was a decline in pneumococcal meningitis and proportion of PCV10 serotypes in the postvaccination period. However, the serotype replacement with non-PCV10 serotypes and penicillin resistance warrant continued surveillance to inform policy. Infectious diseases remain a leading cause of death globally in children below the age of 5 years . In 2019Streptococcus pneumoniae ([Spn] pneumococcus), Haemophilus influenza (Hi) type b (Hib), and Neisseria meningitidis ([Nm] meningococcus) are the 3 main pathogens known to cause morbidity and mortality from acute bacterial meningitis in low-income countries [S pneumoniae to be the leading cause of bacterial meningitis [Although childhood vaccination prevents 2 million deaths a year worldwide, deaths caused by vaccine-preventable diseases among children aged \u22645 years is approximately 2.5 million deaths a year in Africa and Asia . Streptoountries , 5. In 2ningitis .Pneumococcal disease remains a public health concern because it is associated with long-term sequelae and high case-fatality rates (CFRs), which worsen by the rise in resistance to commonly used and affordable antibiotics such as penicillin , 8. An eHaemophilus influenzae type b has almost been eliminated globally due to the highly effective protein-polysaccharide conjugate Hib vaccine, which has been available for over 20 years [In 2015, a global estimate of 29 500 Hib deaths occurred in HIV-uninfected children with an additional 1000 deaths in HIV-infected children . The CFR20 years .Neisseria meningitidis is associated with high fatality and frequency of neurological sequelae and has the potential to cause large epidemics. Although it is observed worldwide, the highest burden of disease is in the meningitis belt of sub-Saharan Africa [n Africa . Approxin Africa . There an Africa . Vaccinen Africa . Althougn Africa . The World Health Organization (WHO) recommended the inclusion of Hib and the PCV10 using a 3 primary-dose series at age 6, 10, and 14 weeks in childhood immunization programs . The intZambia introduced Hib vaccine in January 2004 and PCV10 (3\u2005+\u20050 schedule)  in July  Zambia has been part of the WHO coordinated Invasive Bacterial Diseases Paediatric Bacterial Meningitis (PBM) surveillance network since 2003. In this study, we aim to review PBM surveillance data in Zambia over a 10-year period, 2010\u20132019. The objective of this investigation was to describe confirmed cases of bacterial meningitis and their clinical presentation, pathogen, and serotype distribution in the pre- and post-PCV10 introduction and pneumococcal antimicrobial susceptibility patterns.The study was part of the African PBM sentinel surveillance network initiated by the WHO and other immunization collaborates in 2001. It comprises a robust, hospital-based sentinel surveillance system that collects case-based information on clinically suspected and laboratory-confirmed bacterial meningitis cases among children \u22645 years of age who present to healthcare facilities. The case definitions of suspected, probable, and confirmed bacterial meningitis were used as per WHO guidelines [The time periods were categorized as follows: prevaccine introduction 2010 to 2012, postvaccine period 2014 to 2019, and 2013 as the year of vaccine introduction. Data from the year of vaccine introduction (2013) was not included when comparing the prevaccine against the postvaccine period.The UTH, a national referral hospital in the capital city of Lusaka, is the only Zambian sentinel site. The UTH is a highly specialized referral hospital with several specialty departments. The Children\u2019s Hospital is part of the UTH and has a 400-bed capacity with over 10 000 admissions per year. Approximately 85% of cases received at the Children\u2019s Hospital are referred from district hospitals for specialized care.Sentinel site surveillance was conducted at the UTHs Children\u2019s Hospital. The cases were identified according to the 2003 WHO-recommended standards for surveillance of selected vaccine-preventable diseases and standard operating procedures for bacterial meningitis surveillance .Children who met the case definition had a lumbar puncture performed aseptically by a doctor under the supervision of an experienced pediatrician. Clinical and demographic data were collected from children whose parent/guardian had given informed consent using a WHO standard case investigation form. Once cerebral spinal fluid (CSF) was collected, it was transported to the onsite Microbiology and Chemistry laboratories within 1 hour of collection.2 and MacConkey aerobically. Any residual CSF sample (of at least 50 \u00b5L) was aliquotted and stored in \u221270\u00b0C. Two CSF sample tubes per patient were submitted to the clinical laboratory; 1 for cell count, Gram stain, and bacterial culture and a second for glucose and protein concentrations. Bacterial culture was performed using blood and chocolate agar (containing 5% sheep blood) and MacConkey agar . All plates were incubated for 18\u201348 hours at 35\u201337\u00b0C; blood and chocolate agar in 5% CO3. Pathogen identification was done using conventional phenotypic methods such as colony morphology, growth requirements, Gram stain, and biochemical tests . When avH influenzae, N meningitidis, and S pneumoniae. Identification of pneumococcal isolates received was done using Optochin susceptibility and bile solubility and serotyping of by Quellung reaction using specific antisera . At scheduled intervals, the stored CSF specimens and any corresponding isolates were sent to the Regional Reference Laboratory at the National Institute for Communicable Diseases in South Africa where all samples were tested and genotyped by a multiplex real-time polymerase chain reaction (PCR) for the detection of ctrA, lytA, and hpd genes for N meningitidis, S pneumoniae, H influenzae, respectively [hpd; Nm\u2005=\u2005ctrA; Spn\u2005=\u2005lytA) was \u226435. Polymerase chain reaction detection of RNaseP gene was done to determine sample integrity and the absence of any possible inhibitors, thus confirming true negative PCR results. Detection of the RNaseP gene was used to confirm true negative PCR results; samples with a Ct value \u226536 were reported as PCR inconclusive.The MagNA pure 96 instrument (Roche) was used to extract the total nucleic acid from 200 \u00b5L of all CSFs received, whereas the Applied Biosystems 7500 Fast real-time PCR instrument  was run for the molecular detection of meningitis targeting ectively . The amplytA-positive samples consisted of 8 multiplex reactions and detected 38 serotypes . Samples negative for all 38 serotypes were reported as NEG38 or nonvaccine type [sacB, synD, synE, synG, xcbB, and synF genes for serogroups A, B, C, W, X, and Y, respectively [H influenzae serotyping, targeting acsB (type a), bcsB (type b), ccsD (type C), dscE (type d), ecsH (type e), and bexD (type f) [Real-time PCR genotyping/grouping was then performed on all samples that tested PCR positive for 1 of the 3 genes. Pneumococcal serotyping of ine type , 25. In ectively , whereas(type f) .Streptococcus pneumoniae ATCC strain 49619 was used for quality control purposes.Antimicrobial disc susceptibility testing was performed on viable, culture-positive  Spn isolates. The interpretation of results were done according to the Clinical and Laboratory Standards Institute guidelines . MinimumData were entered into a custom database using Epi Info version 3.5.4  and was analyzed using SPSS statistical software version 20 . Categorical variables are reported as proportion and percentage.t test to measure the significant difference between the proportion of probable cases of males and females, and (3) analysis of variance (ANOVA) to measure the significant difference between the proportion of confirmed cases among the 3 age groups. The surveillance protocol was cleared by WHO and the Zambia Ministry of Health Ethical Review Committee.Using a significance of 0.05 (5%), 3 different statistical tests were used to determine significance. We used (1) the Pearson correlation to measure the strength and significance of the association between the clinical characteristics and the 3 pathogens isolated , (2) unpaired Between 2010 and 2019, 3811 suspected bacterial meningitis cases were reported: 16% (598 of 3811) of them were defined as probable cases, and 37% (221 of 598) were confirmed bacterial meningitis cases. The years 2010 to 2012 were the prevaccination period with a total of 1050 suspected cases, 17% (181 of 1050) probable cases, and 28% (51 of 181) confirmed bacterial meningitis cases, whereas the years 2014 to 2019 were the postvaccination period with 2178 suspected cases, 15% (326 of 2178) probable cases, and 35% (113 of 326) confirmed bacterial meningitis cases. The year of vaccine introduction (2013) had 583 suspected cases, 91 probable cases, and 57 confirmed cases .P = .77). Most of the children were in the 0\u201312 months age group followed by 24\u201359 months and then 12\u201324 months (P = .00), and the post hoc test for difference between each group showing significance at 95% confidence interval on each of the groups.Although suspected and probable meningitis cases were mostly male at 54% (2074 of 3811) and 53% (317 of 598) compared with females at 46% (1737 of 3811) and 47% (281 of 598), respectively, there was no significant difference , and the least common sign was petechial rash at 0.1 (5 of 3811) . Using PIn 93% (3526 of 3811) of the CSF specimens processed, culture- and/or PCR-positive confirmed cases totaled 107 and 221, respectively . Polymerase chain reaction had a higher sensitivity for identification and/or detection of the 3 pathogens compared with culture .Streptococcus pneumoniae showed a downward trend after PCV10 introduction in 2013 with 95% confidence interval of the probability of Spn from confirmed cases (the probability of having Spn from the confirmed cases in 2014 ranges from 26.9% to 70.7% and 28.7% to 87.1% in 2016)  was the most common etiological agent followed by Nm  and Hi  . Streptoin 2016) . Both Hiin 2016) .During the review period, we detected pneumococcal serotypes PCV10 , PCV13 , and NVS ; however, a serotype was not possible from the remaining 9% (14 of 148) because the samples had insufficient deoxyribonucleic acid for serotyping. The predominant were serotypes were 1 and 6A/6B, which accounted for 14% and 11% of Spn cases. Serotype 6A/6B was included in the PCV13 group because PCV13 is known to cover both 6A and 6B; hence, the assumption of cross-protection was considered. The rare Spn serotype 46 detected during the 2012\u20132013 season was the most common among the NVS and accounted for 5% of all the Spn cases . There was an association between the introduction of PCV10 vaccination and decrease in both Spn meningitis and the proportion of PVC10 serotypes in the postvaccination period. However, there was serotype replacement with NVS and unknown serotypes with a combination of vaccine serotype and NVS .N meningitidis  cases were serogroup W.During the 10-year period, serotyped Hi belonged to 74% (23 of 31) Hib and 10% (3 of 31) Hia, whereas the remaining 16% (5 of 31) were unable to be serotyped due to a high Ct. All of the Antimicrobial susceptibility testing was performed on the viable, culture-positive  Spn isolates; 46 of 47 were from the prevaccine period. Sixty-six percent (31 of 47) of pneumococcal isolates were susceptible to penicillin, 55% (17 of 31) of which were PCV10 serotypes and 45% (14 of 31) were non-PCV10 serotypes, with MICs ranging between 0.004 and 0.06 \u00b5g/mL. Susceptibility to ceftriaxone was 98% (46 of 47), 59% (27 of 46) of which were PCV10 serotypes and 41% (19 of 46) were non-PVC10 serotypes, with MICs ranging between 0.008 and \u22640.5 \u00b5g/mL. Of the 47 isolates tested, penicillin-resistant isolates 39% (11 of 28) were PCV10 serotypes and 26% (5 of 19) were non-PCV10 serotypes. Serotype 14 was intermediate to ceftriaxone and was the only isolate from the postvaccination period . The higTo determine the burden of IBD in children \u22645 years, Zambia embarked on sentinel site meningitis surveillance, which provided data before and after PCV introduction. This surveillance has demonstrated that IBD is a public health problem in Zambia. For the first time, we have described the vaccine-preventable bacterial meningitis causative agents, clinical symptoms, and pneumococcal antimicrobial susceptibility patterns in Zambia. The decline in the frequency of probable bacterial and confirmed meningitis cases after PCV10 introduction is notable. The reduction of probable bacterial meningitis cases is consistent with findings by Mpabalwani et al , who obsS pneumoniae  was the most common causative pathogen of meningitis in children <5 years old. Our findings are comparable to findings in other developing countries such as Mozambique [S pneumoniae in the post-PCV introduction era, it is expected that meningitis and pneumonia cases, which are among the top 10 causes of hospital admission of children \u22645 years, would decline further [ In this study, we observed that zambique  and Soutzambique . Likewiszambique . With the 67%, 14 of 221 w The predominant Spn serotypes that cause bacterial meningitis in children \u22645 were serotype 1 and 6A/6B . This finding was similar to what was found in Malawi  and in tH influenzae, the detection of H influenzae remained relatively low at 14% (31 of 221), similar to the findings in Gambia where H influenzae (16%) was the lowest among confirmed meningitis cases [ Although this study did not include the prevaccine period for is cases . Furtheris cases .N meningitidis cases , and all cases belonged to serogroup W. This serogroup was not seen in Zambia until approximately 2010 and replaced serogroup A. After the introduction of MenAfriVac, several countries in sub-Saharan Africa recorded epidemics, and N meningitidis serogroup W was the leading cause [N meningitidis serogroup C were recorded. The serotype replacement can be attributed to the introduction of the meningococcal serogroup A conjugate vaccine (MenAfriVac) in most African countries [ There was a slight increase in confirmed ng cause . The shing cause ; howeverng cause  and Nigeng cause , both ofountries .S pneumoniae to penicillin, with >40% strains with MIC bordering on the nonsusceptible range, suggests the need for prevention of this very serious condition by immunization and ongoing surveillance to monitor changes [ Meningitis requires accurate, prompt diagnosis and antibiotic therapy to ensure favorable outcomes. The reduced susceptibility of  changes . As seen changes  and Nort changes , which rLimitations of this study were that the immunization history for Hib and PCV10 was not available. Patient outcome was not documented. Antimicrobial susceptibility testing was restricted to penicillin and ceftriaxone, and therefore changes in resistance to macrolides and other antibiotics, if any, are unknown. Antimicrobial susceptibility testing was performed on only 47 Spn isolates, 46 of which were from the prevaccine period; therefore, the susceptibility patterns of the postvaccine period was unknown. This study was limited to the children, whose parents gave consent, admitted to the UTH Children\u2019s Hospital in Lusaka, which is a referral hospital and more densely populated, and therefore it may not be representative of the whole country.S pneumoniae, H influenzae, and N meningitidis\u2014were found to be causative agents of meningitis in children aged <5 years, S pneumoniae was still the leading cause, even in the face of high PCV10 coverage. A decrease in confirmed meningitis cases and PCV10 serotypes in the postvaccination period was consistent with a positive impact of PCV10 vaccination. However, the increase in S pneumoniae non-PCV10 serotypes warrants continued PBM surveillance to provide informed guidance on treatment and vaccination policies.Our study has provided valuable information on the burden of vaccine-preventable IBDs. Although all 3 pathogens\u2014"}
+{"text": "The 10-valent conjugate vaccine (PCV10) was introduced into the Extended Program on Immunization in Madagascar. We assessed the impact of PCV10 on the targeted pneumococcal serotypes among children < 5 years of age at Centre Hospitalier Universitaire M\u00e8re Enfant Tsaralal\u00e0na.Between 2012 and December 2018, cerebrospinal fluid (CSF) samples were collected and tested for S. pneumoniae by culture, and antigen tests. The Sentinel Site Laboratory (SSL) referred available CSF samples to the Regional Reference Laboratory (RRL) for real-time polymerase chain reaction confirmatory testing and serotyping.In total, 3616 CSF specimens were collected. The SSL referred 2716 to the RRL; 125 were positive for S. pneumoniae. At the RRL, 115 samples that tested positive for S. pneumoniae were serotyped; PCV10 serotypes accounted for 20%. Compared to the pre-PCV period, the proportion of S. pneumoniae detected declined from 22% to 6.6%, (P < .05), the proportion of PCV10 serotypes as the cause of pneumococcal meningitis cases declined by 26% following vaccine introduction. In our findings, PCV10 introduction resulted in a decline of meningitis caused by S. pneumoniae and PCV10 vaccine serotypes. A recent study from Madagascar showed that about 80% of meningitis cases detected by the PBM network were caused by S. pneumoniae; children aged 1 month to < l year comprised the most cases (71%) [Streptococcus oduction . Pneumocoduction , 3, withoduction . Pediatres (71%) .influenzae type b (Hib) vaccine into the Extended Program on Immunization (EPI) in 2008 and the 10-valent PCV (PCV10) in October 2012. The meningococcal vaccine is as yet not available in the EPI program. A 3-dose infant vaccination of PCV10 without a booster is scheduled in the first 14 weeks of life . PCV10 impact on pneumococcal meningitis and pneumonia hospitalizations in Madagascar was documented in a recent publication: bacterial meningitis fell from 4.5% to 2.6% of hospitalizations and pneumonia hospitalizations decreased from 24.5% to 19.0% [S. pneumoniae and its serotypes following PCV10 and Hib vaccine introduction.In 2006, the World Health Organization (WHO) recommended the inclusion of PCV in all routine immunization programs, especially in countries with high pneumococcal disease burden . The govThis study was conducted at CHUMET, the only sentinel PBM surveillance site in Madagascar. CHUMET reports to the WHO Global Invasive Bacterial Vaccine Preventable Diseases Surveillance Network. PBM surveillance was established in January 2012 at CHUMET. This hospital is an 82-bed public reference pediatric hospital located in the capital of Madagascar and primarily serves local patients, although some patients come from elsewhere in the country. Children \u22645 years old admitted to CHUMET who fulfilled the WHO case definition of suspected bacterial meningitis were eligible for enrollment. A lumbar puncture for routine diagnostic testing was performed on these children.3), leukocytosis (10\u2013100 cells/mm3), and either an elevated protein (>100 mg/dL) or decreased glucose (< 40 mg/dL) [A suspected case of meningitis was defined as a child with sudden onset of fever  in combination with 1 of the following clinical signs: neck/head stiffness, altered consciousness with no other alternative diagnosis, or with other meningeal sign . A proba0 mg/dL) .S. pneumoniae antigen using Alere BinaxNOW Antigen Cards and/or Pastorex Meningitis Bio-Rad latex agglutination test. The Pastorex meningitis kit detects H. influenzae type b, S. pneumoniae, N. meningitidis group , Escherichia coli K1, and group B streptococci.Cases were deemed confirmed pneumococcal meningitis if a pneumococcus was detected in the CSF by 1 of the laboratory methods. CSF specimens collected from suspected cases were tested at the Sentinel Site Laboratory (SSL) and included chemical (glucose and protein concentrations) and microbiological analyses  for the detection of S. pneumoniae isolates were cryopreserved in STGG . Any residual CSF was stored at \u221220\u00b0C and submitted together with available isolates to the Regional Reference Laboratory (RRL) at the National Institute for Communicable Diseases in South Africa, where real-time polymerase chain reaction (RT-PCR), was performed on all CSF specimens received. Total nucleic acid (DNA) was extracted using a MagNA pure 96 instrument (Roche) from each CSF received and extracts were run on an Applied Bio-systems 7500 Fast real-time PCR instrument (Applied Biosystems) for the molecular detection of ctrA, lytA, and hpd genes for confirmation of N. meningitidis, S. pneumoniae, and H. influenzae, respectively [lytA-positive CSFs underwent pneumococcal serotyping by performing 8 multiplex PCR reactions to identify 38 individual serotypes/serogroups [lytA positive but had a negative result in the serotyping PCR were grouped with non-PCV10 serotypes.At the RRL, isolate identification was confirmed by standard laboratory methods and serotyped by the Quellung reaction using serotype-specific antisera (Statens Serum Institut). Minimum inhibitory concentration (MIC) to penicillin and ceftriaxone was performed by broth microdilution method using commercially available Sensititre-SASP2 panels (Trek Diagnostics). Isolates were nonsusceptible to penicillin if the MIC was \u2265 0.12 mg/L and to ceftriaxone if the MIC was >0.5 mg/L according to the Clinical and Laboratory Standards Institute breakpoints .For each eligible case, a case report form was completed. Patient information collected included identity , clinical information , vaccination status, outcome, and discharge (date and diagnosis). Information about vaccination status was confirmed by vaccine card; however, availability of vaccine card documentation was limited. Clinical, SSL data, and RRL results were captured in a database.2 was calculated for testing the difference in positivity between the pre- and post-PCV time periods. P values <.05 were considered significant.Cases reported in 2012 (9 months before and 2 months immediately following vaccine introduction) were considered pre-PCV immunization, and the period following vaccine introduction (January 2013 to December 2018) as post-PCV. \u03c7\u200aS. pneumoniae cases pre- and post-PCV were reported, including their serotype distribution by time periods, age groups, PCV10 serotypes , and non-PCV10 serotypes (serotypes other than these 10 PCV10 serotypes). The samples with mixed PCV10 and non-PCV10 types were considered to be non-PCV10 serotype.This activity was considered routine public health surveillance by Ministry of Health and WHO. All analyses were performed using Microsoft Excel and R version 3.61.S. pneumoniae, 1% (n = 1) H. influenzae, 9% (n = 16) N. meningitidis, 9% (n = 15) group B streptococci, 3% (n = 6) E. coli, and 6% (n = 11) other bacteria of doubtful significance , 9 by culture only, and 31 were by both culture and rapid antigen detection tests , N. meningitidis was detected in 6.8% (n = 13), and H. influenzae was detected in 12% (n = 22) of CSF specimens. Over half  of the specimens where S. pneumoniae was detected by PCR at RRL were negative for S. pneumoniae by culture or antigen testing at SSL; 46% (n = 71) were positive by both PCR at RRL and routine diagnostic tests at SSL  cases CSF specimens were collected and analyzed by routine diagnostic tests at SSL. Of these, 245 were classified as probable bacterial meningitis and 174 were confirmed bacterial meningitis: 72% (n = 125) due to ificance . Of thesificance . Of the on tests . Of the s at SSL .S. pneumoniae detected in 22% (n = 46). During the first 5 full years after vaccination introduction, overall bacterial meningitis and meningitis due to S. pneumoniae decreased. Compared to the pre-PCV period, the proportion of suspected meningitis cases that were determined to be positive for S. pneumoniae, H. influenzae, or N. meningitidis fell from 23% to 10% following PCV introduction (2013\u20132018), and the proportion due to S. pneumoniae declined from 22% to 6.6% of suspected meningitis cases (P < .05). This represents a relative decrease of 57% in bacterial meningitis detected (P < .01) and 70% in S. pneumoniae detected (P < .01) compared to 2012. Throughout the study period (2012\u20132018), S. pneumoniae remained the most common pathogen detected compared with H. influenzae and N. meningitidis; however, the proportion of bacterial meningitis cases due to S. pneumoniae also decreased, from 97.9% to 76.4%. Year on year numbers of CSF specimens tested and the proportions determined to be bacterial, and those confirmed to be due to S. pneumoniae, H. influenzae, and N. meningitidis, are shown in Bacterial meningitis detected by PCR declined after PCV introduction. Of the 207 CSF collected in 2012 and tested at RRL, 23% (n = 47) were positive for bacterial meningitis, with S. pneumoniae detected at RRL, 74% (n = 115) were serotyped and for 26% (n = 41) a serotype determination was not possible due to low DNA concentration (high cycle threshold) in the samples. PCV10 serotypes accounted for 20% (23/115) of specimens collected during the 7 years of surveillance. The non-PCV10 serotypes included single non-PCV10  and mixed serotypes  were 80% (92/115). The proportion of PCV10 serotypes as the cause of pneumococcal meningitis cases declined by 26% following vaccine introduction: 25% (7/28 in 2012) versus 18.4%  (P = .41). All S. pneumoniae isolates (n = 10) were susceptible to both penicillin (MIC \u2264 0.06 \u00b5g/mL) and ceftriaxone (MIC \u2264 0.5 \u00b5g/mL).Of the 156 13\u20132018) . There w13\u20132018) . The decS. pneumoniae due to serotype 2, a non-PCV10 serotype, increased after vaccination introduction and became the most commonly circulating serotype  declined during the period after PCV introduction: serotype 1 was the most commonly detected serotype in 2012, declined in 2013\u20132016, and was not detected in 2017\u20132018; serotype 23F was the most commonly detected PCV10 serotype in 2013 and was not detected in 2014\u20132018. However, the percentage of serotype .S. pneumoniae serotypes disproportionately affected these age groups. The proportion of PCV10 serotypes detected among children aged 1 month to <1 year decreased significantly from 87.5% (n = 7) before vaccination introduction to 56.2% (n = 9) after (P = .01); 1 month to <1 year olds represented a similar proportion of non-PCV10 serotypes before PCV10 vaccine introduction  but had less decline after   and 68.2% (after PCV) occurred in the 1 month to <1-year-old age group, while 21.7% and 21.8% of pneumococcal meningitis cases occurred in the 1 year to <3-year-old age group pre- and post-PCV introduction, respectively. Both PCV10 and non-PCV10  n = 57) . Pneumoc n = 57) . There wP > .05; .S. pneumoniae serotypes after PCV10 introduction in Madagascar. Vaccination information was rarely available from participating children thus the percentage of children enrolled in this study who received PCV10 vaccine is unknown in this population. However, Madagascar national coverage for full vaccination with PVC10 has been not high (69%\u201376% in 2013 to 2018) [This is the first evaluation on the change of Except among neonates, who are too young to receive PCV10 vaccine, and in 2018 when pneumococcal meningitis increased, the incidence of PCV10 serotypes decreased following PCV10 vaccine introduction. The decline was not only observed in pneumococcal meningitis with PCV10 serotypes but also in bacterial meningitis, pneumonia, and total hospitalizations. The decrease in total hospitalizations could be due to the impact of Rotarix, introduced in May 2014, on diarrhea as well as the impact of PCV10 . Also, dH. influenzae, N. meningitidis, and S. pneumoniae, may have been due to the increase of number of enrolled cases. As the number of tested CSF samples increased so did the chance to detect more bacteria. The increase of PCV10 serotypes was a result of the reappearance of serotype 5.In 2018, the increase of incidence of bacterial meningitis, and confirmed for The incidence of non-PCV10 serotypes increased in 2015\u20132018; this may have been related to serotype replacement phenomenon by serotype 2 (56% in 2018). Also, serotype 2 was an issue with meningitis in Bangladesh where it emerged before PCV10 introduction . The repOur study showed that, overall, the predominant PCV10 serotypes (serotypes 1 and 23F) declined during the period after PCV introduction. Similarly, in South Africa, these 3 serotypes were among the PCV serotypes to decrease after PCV implementation . In MozaS. pneumoniae isolates tested at RRL showed susceptibility to both penicillin and ceftriaxone. Despite the low number of isolates tested, this finding is similar to other studies showing the rate of antibiotic-resistant invasive pneumococcal infections decreased in young children after the introduction of the conjugate vaccine [S. pneumoniae isolates was not done because the serotype of each isolate was the same as that detected in the original CSF.All  vaccine . The stuS. pneumoniae isolates was low. However, the number of S. pneumoniae that were not serotyped was also low.The limitations to our study include that it was conducted in only 1 pediatric hospital in Madagascar and may not be representative of trends at other facilities. However, children from outside of the capital city do receive care at this sentinel facility. Additionally, the real percentage of vaccine coverage for the children enrolled in this evaluation was unknown because of the large number of children who had no documented vaccination cards. Finally, the study period before PCV10 introduction was less than 1 year and the overall number of S. pneumoniae serotypes. Ongoing surveillance is essential to keep monitoring these changes, including serotype replacement, to guide further policy decisions [Our study highlights the impact of PCV10 introduction into the national immunization program in Madagascar by reducing pneumococcal meningitis in children aged < 5 years as well as a decline in vaccine-type ecisions ."}
+{"text": "Bacterial pneumonia and meningitis are vaccine-preventable diseases. Sentinel surveillance provides relevant information about their behavior.Fundaci\u00f3n HOMI, Fundaci\u00f3n Hospital Pedi\u00e1trico La Misericordia in 2016. To present the data from sentinel surveillance carried out at the TM 2 system. Bacterial isolates were sent to the Microbiology Group at the Colombian Instituto Nacional de Salud for confirmation, serotyping, phenotypic, and genotypic characterization. Antimicrobial susceptibility profiles were established. We conducted a descriptive study from January 1 to December 31, 2016, on the daily surveillance of patients under 5 years of age diagnosed with pneumonia or bacterial meningitis according to PAHO's definitions. We identified the microorganisms using the automated VITEKS. pneumoniae was isolated in 17 (41%) of them. The most frequent serotype was 19A in five cases (29.4%), and four 19A serotypes were associated with the reference isolate ST320. The incidence rate of probable bacterial pneumonia was 7.3 cases/100 hospitalized patients, and lethality was 2.1%. As for bacterial meningitis, 22 suspected cases were reported, 12 (54%) were probable, four (33%) were confirmed: two by Escherichia coli and two by group C N. meningitidis. The incidence of probable bacterial meningitis was 0.14 cases/100 hospitalized patients. From 1,343 suspected cases of bacterial pneumonia, 654 (48.7%) were probable, 84% had complete Hib vaccination schedules, and 87% had complete pneumococcal vaccination schedules for age. Blood culture was taken in 619 (94.6%) and 41 (6.6%) were positive while Streptococcus pneumoniae serotypes 19A and 3 were the most frequent cause of pneumonia. Spn19A is related to the multi-resistant clone ST320. Strengthening and continuing this strategy will allow understanding the impact of vaccination. Streptococcus pneumoniae, Haemophilus influenzae type b, Moraxella catarrhalis, and Staphylococcus aureus-Pneumonia is one of the most common causes of hospital admissions and death in children under five years of age. In developed countries, viruses are considered the leading cause of pneumonia while the bacterial etiology is proportionally higher in developing countries. The most common causative agents are S. pneumoniae, H. influenzae type b, and Neisseria meningitis,,,Bacterial meningitis, although not as common as pneumonia, is a severe disease with high mortality rates and risk of sequelae. The most frequent agents are HOMI, Fundaci\u00f3n Hospital Pedi\u00e1trico La Misericordia.To initiate the epidemiological surveillance of bacterial pneumonia and meningitis, measure disease burden and the impact of pneumococcal conjugate vaccine (PCV) introduction, and to determine the circulation of serotypes and changes in the susceptibility to antibiotics, the World Health Organization implemented the Global Invasive Bacterial Vaccine- Preventable Diseases (IB-VPD) Laboratory Network. The objective of this work is to present the data from sentinel surveillance carried out at the From January 1 to December 31, 2016, daily surveillance was performed on patients under five years of age admitted to the institution with a diagnosis of pneumonia  or bacterial meningitis . For epidemiological surveillance of acute bacterial pneumonia (ABP), we considered the following definitions established by the Pan American Health Organization (PAHO): Suspected case of pneumonia: Every patient under the age of 5 hospitalized with a diagnosis of community-acquired pneumonia. A hospitalized patient is any patient that requires inpatient treatment. Probable case of bacterial pneumonia: Any suspected case with a chest x-ray showing a radiological pattern compatible with bacterial pneumonia.H. influenzae, S. pneumoniae, or other bacteria were identified or cultured in blood or pleural fluid. Confirmed case of bacterial pneumonia: Any probable bacterial pneumonia case in which  Discarded case of bacterial pneumonia: Any suspected case with no chest X-ray showing a radiological pattern compatible with bacterial pneumonia. Inadequately investigated case of pneumonia: Any suspected case without a chest x-ray.We reviewed patients' records every day. Chest x-rays were performed to screen suspected cases, two peripheral blood cultures were taken from probable cases and, in the presence of pleural effusion, a culture of the pleural fluid was taken. Pediatric radiologists interpreted chest X-rays according to the World Health Organization (WHO) manual of diagnostic imaging We considered all children under five years of age hospitalized with a medical diagnosis of meningitis as a suspected case of meningitis; these patients underwent lumbar puncture and blood cultures. The case was considered as probable if the cerebrospinal fluid (CSF) had any of the following characteristics: Turbidity, increased leukocytes (> 100/mm3), or leukocytes between 10-100/mm3, and elevated protein (> 100 mg/dL), or low glucose levels (< 40 mg/dl). All suspected cases with a bacterium recognized for causing meningitis in blood or CSF were considered as confirmed cases. Discarded cases included those suspected with CSF cytochemical values not compatible with meningitis and negative cultures. Finally, any suspected case without a CSF sample was considered inadequately investigated.https://paiweb.gov.co.) and Bogota's web page .We collected the clinical data for all patients included in the surveillance, as well as the information from their vaccination cards, and when they did not have them, we systematically searched for the records in the Expanded Immunization Program (PAI) website  while bacterial isolates were sent to the Microbiology Group at the Instituto Nacional de Salud by Bogota's public health laboratory for confirmation, and phenotypic and genotypic characterization. The pneumococcal isolates were serotyping by Quellung reaction, serogroup of N. meningitidis, and the serotype of H. influenzae was determined by the slide agglutination assay using commercial antisera . We determined the antimicrobial susceptibility profiles using the disk diffusion test (Kirby- Bauer) and microdilution in broth to determine resistance to penicillin (PEN), ampicillin (AMP) ceftriaxone (CRO), trimethoprim-sulfamethoxazole (SXT), chloramphenicol (CHL), tetracycline (TET), erythromycin (ERY), and rifampicin (RIF). Results were interpreted based on the criteria of the Clinical & Laboratory Standards Institute (CLSI) 2016 standards The sentinel institution identified the microorganisms isolated in cultures using the automated VITEKet al. 9V-ST156, Colombia23F-ST338, and Netherlands3-ST180 clones, as well as the representative isolates of ST199, ST276, ST320, ST460, and ST473 sequence types, as electrophoretic reference standards. We analyzed PFGE patterns with GelCompar II version 4.0 using the unweighted pair group method with arithmetic mean (UPGMA) and the Dice coefficient with optimization and tolerance of 1.5% to generate a genetic similarity dendrogram. PFGE patterns with similarity over 75% were grouped as a clonal group and designated with capital letters.We conducted additional studies to those suggested in the protocol for a better characterization of the isolated agents. For the genotypic characterization, we used pulsed-field gel electrophoresis (PFGE) according to the protocol by Vela, HOMI, Fundaci\u00f3n Hospital Pedi\u00e1trico La Misericordia is a private tertiary referral hospital located in Bogot\u00e1, which treats children with bacterial pneumonia and bacterial meningitis. Between 2011 and 2015, 206 cases of invasive pneumococcal disease (IPD) in children under five years of age were reported in Bogot\u00e1, 48 (23%) of them by Fundaci\u00f3n HOMIThe We identified the risk of selection bias in the study since it was conducted in a tertiary care hospital where patients with more severe diseases are admitted. We also acknowledged the probability of bias in the analysis of the chest X-rays. There was also the possibility of bias risk due to the loss of microbiological isolates during the process for which we developed a protocol for sending the samples and verifying their viability upon arrival at their destination.This was a descriptive study. We collected the data in an Excel database, performed frequency analyses of the variables, and estimated the average length of stay in the intensive care unit (ICU) and the incidence of pneumonia and meningitis per 100 hospital admissions.HOMI, Fundaci\u00f3n Hospital Pedi\u00e1trico La Misericordia.This was a risk-free study since the patients did not undergo any intervention, procedure, or test besides those indicated for the diseases. It was approved by the Ethics and Research Committee at the During the study period, 1,343 suspected cases of bacterial pneumonia were captured; 654 (48.7%) met the probable case criteria, 380 (58%) were children under 2 years of age, 358 (55%) were male, and 296 (45%), female. Among the 654 probable cases, there were 13 children under the age of 2 months; of the 641 patients older than 2 months, 539 cases (84%) had complete Hib vaccination schedules for age , 61 (9.5%) had incomplete schedules, and 41 (6.4%) had no vaccination records. Finally, 559 cases (87%) had complete pneumococcal vaccination schedules for age, 41 (6.4%) had incomplete schedules, and 41 (6.4%) had no vaccination records. All patients vaccinated against pneumococcus received PCV10.H. influenzae type b vaccine administered to the confirmed cases. Most of the patients with pneumococcal isolation had received at least 2 doses of the vaccine, while three with serotypes 14, 3, and 19A had received 3 doses of PCV10. It was not possible to obtain vaccination data for the only case with H. influenzae type b isolate. Among the probable cases (n=654), the most frequent radiological findings were consolidation (54.5%), other alveolar opacities (40.2%), pleural effusion (3.2%), and interstitial opacities (1.9%). Of these cases, 185 (28.2%) were admitted to the intensive care unit (ICU) with an average stay of five days.S. pneumoniae was isolated in 17 (41%) of them  cases, followed by serotypes 3 and 14 with 4 (23.5%) cases, respectively. Isolates with type 19A capsules were resistant to PEN, CRO, STX, ERY, and TET; serotype 14 was resistant to PEN, CRO, and STX while isolates with serotypes 3, 6A, 9N, and 15A were susceptible to all antibiotics tested (Blood culture was done in 619 (94.6%) probable cases, 41 (6.6%) of which were positive;  of them . All S. s tested . The 16 s tested . Group AHaemophilus influenzae was isolated in eight (19.5%) of the 41 patients with positive cultures; of them, five (62.5%) were non-typeable, one (12.5%) was serotype b, and one (12.5%) was serotype a while no serotype was obtained in one case (12.5%). All isolates were sensitive to AMP, CRO, SXT, RIF, CHL, and TET. N. meningitis serogroup C was found in a patient diagnosed with pneumonia and meningitis. There were three cases of empyema, S. aureus was documented in two of them, and the culture was negative in the third patient.S. pneumoniae serotype 3 was isolated in two of these patients and the remaining 12 patients had negative cultures.During the study period, 8,557 children under 5 years of age were hospitalized in the institution. The incidence rate of clinical pneumonia (suspected cases) was 15.2 cases per 100 hospitalized patients while the incidence rate of probable bacterial pneumonia was 7.3 cases per 100 hospitalized patients. Finally, 14 (2.1%) of the 654 probable cases died; E. coli and two by group C N. meningitidis. None of the cases had received meningococcal vaccination. The incidence of probable bacterial meningitis was 0.14 cases per 100 hospitalized patients.As for bacterial meningitis, 22 suspected cases were reported, of which 17 (77%) were under 2 years of age. Of the suspected cases, 12 (54%) were probable and 7 (75%) were patients under 2 years of age. Of the 12 probable cases, four (33%) were confirmed: two by HOMI, Fundaci\u00f3n Hospital Pedi\u00e1trico La Misericordia,, essential to understand the epidemiological behavior of these two vaccine-preventable diseases and determine the prevalence of circulating pneumococcal serotypes in the period of study.We present here the data from the first year of sentinel surveillance of meningitis and pneumonia in children under 5 years of age treated at the HOMI, Fundaci\u00f3n Hospital Pedi\u00e1trico La Misericordia. The objectives of this network are to collect information to describe the epidemiology and burden of vaccine-preventable bacterial invasive diseases, implement a surveillance system to measure the impact of vaccine introduction (Hib or PCV), and detect and characterize circulating serotypes.As of 2016, the Global Invasive Bacterial Vaccine-Preventable Diseases Laboratory Network has included 58 countries, among them Colombia, and 123 sentinel hospitals, such as the In 2006, Colombia introduced the vaccination against pneumococcus with PCV7 Later, in the period 2010-2011, due to the withdrawal of the heptavalent vaccine, the PCV13 vaccine was acquired to continue with the immunization of the target population, as well as to complete and finish schemes initiated with the heptavalent vaccine. In 2011, the PCV10 vaccine was universalized in the country and began to be administered in January 2012 to the population born on or after November 1, 2011, using a two-dose schedule and boosters at 2, 4, and 12 months of age. This vaccine is currently administered with 89% coverage including a booster administered in 2016.S. pneumoniae, H. influenzae, S. aureus, and the influenza virus are the most frequent causes of pneumonia -,Pneumonia is the leading cause of death from infectious diseases in children under 5 years worldwide and accounts for 15% of all deaths, mostly in developing countries Saludcoop hospital network in Bogot\u00e1, with 35.1% probably due to the inclusion of patients aged 0-36 months only, in whom the prevalence of viral cases is higher Furthermore, we found that 48.7% of the suspected cases met the diagnostic criteria of probable case. This percentage is higher than that reported in a previous study conducted by the Regarding clinical findings, fever was the most common symptom similar to the reports of other studies ,,-,The WHO pneumonia surveillance protocol is based on chest X-ray results et al. (6.1%) and Jain, et al. (8%) ,et al. previous study in Bogot\u00e1 (1.5%)et al. (2.1%) et al. (3.1%) et al. (1.1%) 2 chamber and the use of automated methods for the identification of microorganisms. The number of patients admitted to the ICU (28.2%) was similar to that reported by Tiewsoh, et al. (20.8%) et al. (21%) et al. (10.5%) et al. (<1%) ,The percentage of positive blood cultures (6.6%) was similar to that found by Lakhani, The clinical pneumonia incidence rate was 15.2 cases per 100 hospitalized patients while probable bacterial pneumonia was 7.3 cases per 100 hospitalized patients. Between 2009 and 2015, 31% of hospitalizations of children under 5 years in Colombia were associated with acute respiratory infections (ARI) (J00-J22) including some codes (J00-J09 and J19-J22) that are not subject to sentinel surveillance A study conducted in Bogot\u00e1 in healthcare delivery centers of the Saludcoop network before the systematic administration of the conjugate vaccine found an incidence of clinical pneumonia of 6,276 cases/100,000 patients under 36 months and confirmed pneumonia through imaging in 2,120 cases/100,000 patients under 36 months ,Mortality from ARI in Colombia decreased between 2007 and 2016 from 24 to 13.9 cases per 100,000 children under 5. In Bogot\u00e1, the trend has been similar with a decrease in ARI mortality from 6.1 to 4.3 per 100,000 children under 5 S. pneumoniae isolates were resistant to one or more antibiotics and 29.5% were multidrug-resistant. Over the past two decades, S. pneumoniae has become increasingly resistant to several antibiotics including cephalosporins, macrolides, and fluoroquinolones, and estimates are that 20-30% of pneumococcal disease cases worldwide are multidrug-resistant In our study, 53% of the S. pneumoniae clones, are a leading cause of pneumonia in children under 5 Our results show that serotypes 3, 14, and 19A, which are genetically related to international et al.'s S. pneumoniae serotype 19A associated with the spread of ST320, a variant of the international clone Taiwan19F14-ST236, have been reported worldwide and constitute one of the most frequent causes of pneumococcal disease As in Parra, S. pneumoniae serotypes causing IPD in children under 5 from 1994 to 2016 published by the National Health Institute ,,A meta-analysis reaffirmed the predominant contribution of 19A to invasive pneumococcal disease in children from different regions in the world after the introduction of PCV7 as it was identified as the most common serotype in cases from the Americas, Europe, and Western Pacific regions S. pneumoniae isolates carrying this capsular type Serotype 3 isolates were associated with the Netherlands3-ST180 clone, which in turn is associated with 95% of invasive Colombian et al. in India (12.5%) S. pneumoniae or H. influenzae type b while two cases of meningitis due to N. meningitidis were reported. In 2016, 19 cases of S. pneumoniae, 23 of H. influenzae type b, and 38 of N. meningitidis meningitis in children under 5 were reported to the national surveillance system As for bacterial meningitis, the proportion of probable cases compared to suspected ones was 54% higher than the reports by Ramachandran, Instituto Nacional de Salud, the Pan American Health Organization (PAHO), and the Secretar\u00eda Distrital de Salud de Bogot\u00e1. Other strengths are the prospective collection of data and the characteristics of the sentinel hospital, which serves a significant number of the city's patients with IPD and has the infrastructure and epidemiological support to ensure good data quality. Study requirements were met, and patient recruitment and analysis complied with PAHO standards.One of the strengths of our study was the coordinated participation of all actors responsible for epidemiological surveillance: the Ministry of Health and Social Protection, the Regarding limitations, the study was conducted in a tertiary care hospital in Bogot\u00e1 and the data may not be extrapolated to other populations. Another limitation was the difficulty in obtaining vaccination data for all patients because the information system (which is the source of the data) was not up to date. There may also be biases derived from radiological interpretation. Finally, this study does not allow determining the impact of the vaccines as this requires sustained surveillance data for a 3 to 5 year period.Streptococcus pneumoniae is the most common cause of pneumonia while the most frequent serotypes were those not included in PCV10 . Serotypes 19A and 14 are multi-resistant. The second most common bacterium was non-typeable H. influenza and one case of H. influenza type b was reported. There were two cases of meningitis due to group C N. meningitidis. Epidemiological sentinel surveillance is a strategy that provides insight into the epidemiological behavior of vaccine-preventable diseases. Strengthening and continuing this strategy will allow a better understanding of vaccination impact."}
+{"text": "To assess the ability to work of Polish nurses by age groups.The ability to work is widely discussed in the literature in the context of nurses' productivity; thus, it is necessary to identify the ability to work when facing an increasing demand for services.The observational study involved 349 professionally active nurses aged 46.9\u00a0\u00b1\u00a09.7\u00a0years, with a length of service of 23.5\u00a0\u00b1\u00a09.6\u00a0years. The Work Ability Index (WAI) was used to assess the nurses' ability to work.rs\u00a0=\u00a0\u22120.324, p\u00a0<\u00a0.000) and with seniority . Nurses with higher education presented higher Work Ability Index scores. Also, the age , work seniority  and education  affect work ability.The ability to work decreases with age (The ageing process and seniority of nurses negatively affect their ability to work. A lack of programmes to maintain physical condition for nurses can result in a shortage of staff.Programmes can be developed to create or improve healthy working environments to increase productivity. Concerns about possible future shortages of nurses are growing in many OECD countries as the demand for nursing services is expected to rise when facing an ageing population and the gradual retirement of nurses belonging to the Baby Boom generation. These concerns have led many countries to increase the number of institutions for nurse training  will double from 25.9% to 50.2%  and the ageing process. It was investigated how the ability to work is affected by age, work seniority and nurses' level of education. The literature review shows that the ability to work may vary according to age group  Provincial Specialist Hospital, (b) Provincial Specialist Hospital, Research and Development Center, (c) University Clinical Hospital and (d) Military Clinical Hospital with Polyclinic. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines for reporting of observational studies were followed .2.3The questionnaires were distributed to the nurses during their briefing about the research in the above\u2010mentioned hospitals' conservative and surgical wards at the beginning of July 2018. Participation was voluntary and anonymous. After completing the questionnaire, each nurse placed it in an envelope and turned it in at the agreed location. At the end of August 2018, the questionnaires were collected and statistically analysed.2.4Data were collected using the Work Ability Index (WAI) questionnaire, which is used to assess health care professionals' level of work ability. The questionnaire was adapted for use in Poland by Pokorski . ThroughThe WAI results from research by the Finnish Institution of Occupational Health (FIOH) employees . All participants gave written informed consent after a thorough explanation of the procedures involved. The study was carried out following the tenets of the Declaration of Helsinki.2.6Sample size analysis was performed in Statistica 13 . Based on the results obtained in the hospital, the sample size was assessed in a pilot study. It was assessed how the ability to work in a professionally active group of nurses differed according to age. The pilot study was conducted among nurses aged under 30 and over 30. Means and standard deviations of WEI results in both groups were used to estimate the sample size. The sample size was estimated with a two\u2010sample unpaired\u2010means test (unpaired t test). Parameters: the mean score in the youngest group was 40.4 (SD\u00a0=\u00a06.1); the mean score in the oldest group was 38.1 (SD\u00a0=\u00a08.9); the alpha level was set at 0.05 and the power of the test at 0.9. It also assumed no correlation of evaluated variables and adopted a 2\u2010sided null hypothesis. The estimated sample size necessary was 316 participants based on the parameters. Also, the risk of losing participants (20%) was assumed. The final estimated sample size needed was 348 participants. The final sample size in this research was 349 participants.U test. The correlation between the examined variables was performed using Spearman's rank correlation coefficient (rs).The data obtained during the survey were collected and systematized using Microsoft Office Excel spreadsheet tools. The statistical analysis was conducted using Statistica 13  under licence from the Wroclaw Medical University, Poland. For measurable variables, arithmetic means, medians, standard deviations, and the range of variability  were calculated. For qualitative variables, the frequencies (per cent) were calculated. All investigated quantitative variables were checked with the Shapiro\u2013Wilk test to establish the type of distribution. Comparative analysis was performed using non\u2010parametric tests \u2013 ANOVA Kruskal\u2013Wallis rank with the post hoc test or Mann\u2013Whitney p\u2010value in the univariate model was less than or equal to 0.50. For the overall study, a value of p\u00a0<\u00a0.05 was considered statistically significant.An analysis of the impact of selected factors on work ability assessment was performed using linear regression . A non\u2010standardized and standardized regression coefficient, standard error and level of statistical significance were determined. The next step was constructing the multi\u2010factor model (progressive step method), taking into account the variables whose 33.1n\u00a0=\u00a0347) of the participants were female. Regarding age group distribution, the highest percentages were recorded in the age groups of 41\u201350 and 51\u201360\u00a0years: 42.7% and 34.4%, respectively (Table\u00a0The mean age of the studied nurses was 46.9\u00a0\u00b1\u00a09.7\u00a0years (median 48), and the mean length of service was 23.5\u00a0\u00b1\u00a09.6\u00a0years (median 26). Over 99% (3.2p\u00a0<\u00a0.001) in the WAI score were found between ages 21\u201330 and ages 41\u201350, 51\u201360 and over 60, as well as between ages 31\u201340 and ages 41\u201350, 51\u201360 and over 60 . In the youngest age group (21\u201330), the WAI median's value was 42 points, which corresponds to the category of good ability to work. In the age group of over 60, the median WAI dropped to 31.5 points, which corresponds to the category of moderate work ability . The analysis of the relationship between the WAI and the work position of nurses, work in more than one place, hospital ward did not show statistically significant differences (p\u00a0>\u00a0.05) , work seniority  and education  on work ability. The multifactorial model showed a statistically significant impact of seniority on work ability. For people with longer work experience, the ability to work decreases  is, of course, not limited to Poland; it is a reality that many other countries face both Europe and worldwide. In Europe, Scandinavian countries \u2013 most notably Sweden \u2013 exhibit the highest ratios of older people , the average value of the WAI was the highest, amounting to 41 points, which means good ability to work. In the oldest age group (over 60), the average WAI was 30 points, which means moderate ability to work.In their study on the application of the WAI to people over 50\u00a0years of age, \u010celedov\u00e1 et\u00a0al.\u00a0 comparedConsidering the ageing of the occupational group of nurses and their shortage in the health care system, one should expect that they would prolong their employment after reaching retirement. That is not the case; however, Bugajska et\u00a0al.\u00a0 and Heya4.1The study has several limitations. The study group is highly feminized, which reflects the fact that females dominate the nursing profession. Therefore, it was impossible to compare the ability to work between the two genders. Given the physiological and psychological differences between women and men, such a comparison might reveal differences in work ability. Future studies should ensure that a more representative sample of both sexes is selected. Another limitation may have been the difficulty of completing the questionnaire: some questions may have been hard to understand for some respondents. A more advantageous solution would be to ensure the researcher's participation in the questionnaire completion by each respondent. The WAI seems to be a good source of information on potential limitations to the exercise of daily professional duties.5Regarding nursing practice, based on the results of this study, programmes can be developed to create or improve healthy working environments that will help prevent occupational diseases and consequently increase productivity. Such measures can also serve to reduce workload and the ensuing fatigue and to increase employee motivation. This study showed that nurses with shorter work experience have a higher ability to work, and this may be due to the fact the workload was higher for those nurses working longer. The lack of development and implementation of a preventive programme for nurses that would enable them to maintain good physical fitness levels, translating into an increased ability to work, may result in a severe shortage of nursing staff in the near future.6The nurses surveyed showed a moderate ability to work, which is related to the ageing of this occupational group. This is a significant challenge for the health care system, given that the largest group of nurses was between 41 and 60\u00a0years of age. Also, it was observed that nurses with shorter work experience have a higher ability to work.No conflict of interest has been declared by the authors.\u0141R, IW and JR made substantial contributions to conception and design. \u0141R was responsible for data collection. IW, PK and AK analysed data. \u0141R and IW drafted the manuscript. JR, PK and AK revised manuscript critically for important intellectual content. All authors have participated sufficiently in the publication process to guarantee its content and take full public responsibility for the reported study, including its findings and conclusions. The final version is approved to be published by all authors.The research project was approved by the independent Bioethics Committee of the Wroclaw Medical University . The study was performed in accordance with the Declaration of Helsinki of the World Medical Association."}
+{"text": "Genetic patterns of inter-population variation are a result of different demographic and adaptive histories, which gradually shape the frequency distribution of the variants. However, the study of clinically relevant mutations has a Eurocentric bias. The Romani, the largest transnational minority ethnic group in Europe, originated in South Asia and received extensive gene flow from West Eurasia. Most medical genetic studies have only explored founder mutations related to Mendelian disorders in this population. Here we analyze exome sequences and genome-wide array data of 89 healthy Spanish Roma individuals to study complex traits and disease. We apply a different framework and focus on variants with both increased and decreased allele frequencies, taking into account their local ancestry. We report several OMIM traits enriched for genes with deleterious variants showing increased frequencies in Roma or in non-Roma . In addition, previously reported pathogenic variants also show differences among populations, where some variants segregating at low frequency in non-Roma are virtually absent in the Roma. Lastly, we describe frequency changes in drug-response variation, where many of the variants increased in Roma are clinically associated with metabolic and cardiovascular-related drugs. These results suggest that clinically relevant variation in Roma cannot only be characterized in terms of founder mutations. Instead, we observe frequency differences compared to non-Roma: some variants are absent, while other have drifted to higher frequencies. As a result of the admixture events, these clinically damaging variants can be traced back to both European and South Asian-related ancestries. This can be attributed to a different prevalence of some genetic disorders or to the fact that genetic susceptibility variants are mostly studied in populations of European descent, and can differ in individuals with different ancestries. CFTR gene, while the most common causal variant in South Africans with African ancestry is 3120 + 1G\u2192A, and different mutations have different therapeutic targets  and genome-wide array data of 89 healthy Spanish Roma individuals and characterize the functionally relevant genomic variants  with either increased or decreased allele frequencies in the Roma. Beyond frequency distribution differences, and taking into account that Roma is an admixed population, we describe the ancestral origin of multiple variants by leveraging on the estimated local ancestry of their background haplotypes.We used WES (mean depth of 54X), and genome-wide autosomal SNP data (Affymetrix Axiom Genome-Wide Human Origins 1 array) for Spanish Roma individuals  , depositThe phasing of the merged WES-array dataset, with 405,814 variants with minor allele frequency (MAF) > 1%, was performed using SHAPEIT , using tWe computed the allele sharing ratio (proportion of variants at different frequency bins) from the Roma segregating in non-Roma populations from WES variants dataset. In addition, we compared the linkage disequilibrium (LD) decay patterns between Roma and non-Roma from the genome-wide array dataset using PopLDdecay  with defalleles or Nhom per individual per gene). Although we expect that the most constrained genes  will be shared across populations, we test whether there is a particular pathway enriched in the most mutated genes in the Roma samples and the non-Roma groups, independently. To do so, we normalized Nalleles or Nhom by the number of variants in each gene and we then examined the correlation between each pair of Roma to non-Roma populations per each gene. The over-representation analysis was performed with default parameters . The total number of deleterious alleles per individual is similar among Roma and non-Roma groups  with increased frequencies in South Asian groups , which is associated with obesity in Asians , has significantly higher frequencies in Roma (8.6%) compared to all non-Roma (<1.5%)  , 5. This (<1.5%) , suggest (<1.5%) . These r (<1.5%) , althoug (<1.5%) .ADH1B gene reported to be protective for alcohol dependence (rs1229984) shows a significantly higher allele frequency in Roma without a clear ancestry origin  breast tumors , while there are 84 and 74 segregating in IBS and TSI, respectively.ITGB3 gene (chr17:45360730), reduces the efficacy of aspirin and clopidogrel  reduces the treatment efficacy for obesity and type II diabetes   exhibit inter-population genetic variation in the human genome, as mentioned above. Regarding drug binding domains, we identified 101 variants in our dataset that disrupt the domains without being deleterious for the protein. This set is less biased toward European genetic variation, since it is based on impact prediction, rather than on previously discovered genetic associations . Only 26pidogrel  (indicatpidogrel . A variaglutide)  and its glutide) .CRYZ gene (chr1:75175886) with significantly higher MAF in Roma and South Asians than in Europeans   , we idenporosis) . Four Roporosis) , which sWe next examined previously described variants in ADME genes. In our dataset, 14 out of 95 of them show increased MAF with a fold change equal or higher than 1.5 comparing Roma and non-Roma . Some vaThe screening beyond disease-associated variants in the Roma population reveals that most of them can change the response of drugs used for metabolic and cardiovascular disorders and that they might have a European origin. However, this analysis is based on the impact prediction and it is important to take into account that the phenotype is also influenced by the environment, non-coding variants and regulatory elements, among others.The underrepresentation of human populations in genetic studies impairs the understanding of genome architecture and exacerbates health differences. In order to overcome this limitation, the Eurocentric bias in the discovery of functional variants has to be taken into account . In the Triple negative refers to the overexpression of three common markers   . Howeverncogene)  or Roma ncogene)  patientsIn the present study, we also examine previously defined disease-associated variants. Besides confirming the ancestry origin of some Mendelian mutations in the Roma, we provide new evidence: the risk allele responsible for Acetyl-coA dehydrogenase deficiency (rs77931234) is traced to a South Asian-like ancestry, while the risk alleles for Charcot\u2013Marie\u2013Tooth disease variants  show European-related ancestry. In addition, we perform a comprehensive study of the pathogenic variation reported in ClinVar database . The resCYP2C19 polymorphism (rs4244285) in Hungarian and Portuguese Roma groups  are designed to predict the phenotype from genetic data, combining the effect sizes of multiple variants and their frequency . HoweverHere, we provide new evidence of a different frequency spectrum of clinically relevant variants across populations: while some have increased allele frequencies in the Roma, others are virtually absent. This was possible due to the availability of a substantial number of whole-exome sequences at high coverage, which allows the study of clinically relevant genetic variation, enriched in low frequency variants . HoweverWe would like to remark that this study does not aim to exacerbate the importance of inter-population variability, to justify health differences in minority ethnic groups, or to advocate for racialized medicine. In fact, genetic ancestry is not the only determinant of ethnicity or health, and social factors should be considered. Given that genetic diversity is a continuum, large scale genome-wide studies are needed to fully capture and represent human variation, without excluding any population while respecting their rights and interests and properly accounting for demographic differences. This would prevent the current overgeneralization of the results obtained from genetic studies on populations with only European ancestry in the assessment of disease risk testing and treatment response .The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the CEIC-Parc de Salut Mar 2019/8900/I. The patients/participants provided their written informed consent to participate in this study.NF-P and DC contributed to the design and conception of the study. NF-P performed and implemented the data analysis. All authors contributed to the interpretation and discussion of the results and writing of the manuscript, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest."}
+{"text": "Adverse events in healthcare are inevitable as most treatments and investigations have the potential to cause harm. Healthcare providers often witness or are involved in adverse events, putting them at risk of becoming second victims, which may further impact patient safety.The researchers report on the physical and psychological symptoms experienced by healthcare providers following adverse events during patient care as well as their perceptions of the quality of support received and the desired forms of support following adverse events.A single secondary public hospital in the Limpopo province, South Africa.Using total population sampling, healthcare providers were invited to anonymously participate in a cross-sectional survey using the Second Victim Experience and Support questionnaire to assess experiences after adverse events and desired forms of support.N = 181) experienced more psychological distress  than they experienced physical distress. Most healthcare providers relied on non-work-related support . Healthcare providers reported that adverse events influenced their perceptions of professional self-efficacy  and mostly desired support in the form of discussing the event with supervisors or managers .Healthcare providers (Healthcare providers in different clinical settings are at risk of suffering second victim effects. Health institutions should offer support to all victims of adverse events.The information offered could enable healthcare management to modify existing practices to a non-punitive style, improve communication and provide better support following adverse events. In healthcare settings, optimal care is achieved by providing safe, quality care and preventing injuries. In developing countries, eight out of every 100 patients suffer from healthcare-related adverse events  who have been exposed to an adverse event to participate in the study. In alphabetical order, healthcare providers included antiretroviral counsellors and testers, dieticians, dentists and dentist assistants, doctors, forensic pathology workers, nurses, occupational therapists, optometrists, pharmacists, porters, physiotherapists, psychologists, radiographers, and speech and audiology therapists. All participants who volunteered to participate in the study signed an informed consent form.The authors adopted total sampling, inviting all healthcare providers delivering direct healthcare to patients  using Kruskal-Wallis tests see .Ethical approval was obtained from the Faculty of Health Research Ethics Committee of the University of Pretoria (No: 287/2020) and the Limpopo Department of Health South Africa (L-2020-05-09). The Chief Executive Officer of the selected hospital also approved the study. The first author visited all the heads of departments in the hospital to inform them about the study.n = 593), 181 completed the questionnaire, representing a response rate of 30.5%. The healthcare providers included 118 nurses, 24 medical doctors and 39 allied healthcare providers. Allied healthcare providers included antiretroviral counsellors and testers (n = 5), dieticians (n = 2), dentists (n = 5), dental assistants (n = 2), forensic pathology workers (n = 2), porters (n = 4), an occupational therapist (n = 1), an optometrist (n = 1), pharmacists (n = 8), physiotherapists (n = 4), psychologists (n = 3), radiographers (n = 1) and a speech and audiology worker (n = 1).Of the eligible healthcare providers involved in direct patient care (n = 37) of participants did not specify their age. The participants comprised 83.4% (n = 151) women and 16.6% (n = 30) men. Of these participants, 43.6% (n = 79) were married and 56.4% (n = 102) stated that they were single. On average, participants had 13.5 (SD = 8.79) years\u2019 work experience, with 29.8% (n = 54) working in the same healthcare institution for 11\u201315 years.The participants were on average 42.35 years old (standard deviation [SD] = 9.825 years); 20.4% .This group of healthcare providers see  more oftAdverse events affected healthcare providers\u2019 professional self-efficacy the most (2.71) followed by turnover intentions (2.56) and absenteeism (2.08). In this study, healthcare providers experienced professional doubt following adverse events, which affected them more than influencing their desire to leave the profession or being absent from work.Healthcare providers were supported largely by non-work-related structures (4.08), followed by supervisor support (3.43), support from colleagues (3.30) and support from their institution (2.94). In this setting, institutional support was limited and non-work-related support was regarded as effective. Healthcare providers mostly desired support in the form of needing to discuss the event with a supervisor or manager .A significant number of healthcare providers, from different health specialties, experienced psychological distress following an adverse event. The psychological distress was more pronounced than any physical distress. These findings are similar to other studies describing the experience of healthcare providers on adverse events  lockdown in South Africa where healthcare providers were inundated with dealing with a pandemic and ever-changing practice. In addition, the data were collected over a restricted time period, introducing the potential for recall bias. The findings are limited to a selected hospital in South Africa and therefore may limit the generalisation, and the type and timing of adverse events were not investigated.All healthcare providers take an oath to \u2018do no harm\u2019. While healthcare providers strive to meet this ethical expectation, unexpected harm still occurs in the healthcare environment. When an adverse event occurs, the first victim is the patient, and their family, with healthcare providers often being the second victims. Institutions are obliged to support all the victims affected by the adverse event. Good support may minimise effects, such as a loss of confidence, which is important for healthcare providers. Lack of support may increase the duration of negative effects, which may ultimately lead to healthcare providers desiring a change of occupation. This study revealed that healthcare providers in the Limpopo province experience adverse events and are second victims. These healthcare providers need timely support to be able to perform optimally."}
+{"text": "BackgroundAs a well-documented fact, metastatic brain tumors are the most common cause of brain tumors in adults, with an incidence of 9-17%, based on various studies, although it was thought to be higher. The aim of this study was to describe recorded cases of metastatic brain tumors in the adult population of a tertiary care and oncology center in Jeddah, Saudi Arabia.MethodsThis study was conducted at King Abdulaziz Medical City (KAMC) at King Khalid Hospital in Jeddah, Saudi Arabia, including records from January 2016 to December 2020. The study implemented a retrospective cohort design to fulfill its aim. A data collection sheet containing demographic data such as age and gender, and information pertaining to the primary pathology, multiplicity, and survival outcome was used.ResultsA total number of 213 patients were enrolled in this study. Overall, 68.1% of the sample comprised of females. Approximately two-thirds (61.9%) of the patients\u2019 imaging results revealed multiplicity, whereas the remaining third (38.1%) had solitary lesions. The estimated overall survival median after the diagnosis of brain metastasis was six months (95% CI: 5.5-6.5).ConclusionWe recommend conducting a nationwide study to better understand the incidence in accordance to geographical and gender differences. We can further expand our research to include other institutes in Saudi Arabia, and include important predictors such as time from the diagnosis of primary pathology to brain metastasis, disease progression cost, and disease progression in the months prior to the patients\u2019 death. Although brain tumors account for less than 2% of all tumors worldwide, they are considered one of the most fatal cancers . A totalStudy design, area, and settingsThis was an observational study conducted at King Abdulaziz Medical City (KAMC) at King Khalid Hospital in Jeddah, Saudi Arabia. The retrospective cohort study design included records from January 2016 to December 2020. KAMC is a non-profit tertiary care hospital in Jeddah, Saudi Arabia, that provides high-standard patient care. Located in KAMC, Princess Noorah Oncology Center, a leading cancer center in the region and the most prominent cancer center in the Western Region of Saudi Arabia, serves the Western, Northern, and Southern parts of the Kingdom.Identification of study participantsPatients with established primary tumors (controlled or active) outside the central nervous system (CNS) with evidence of brain metastases, aged 18 years and above, and treated in KAMC inpatient and outpatient facilities were included. Those with an initial diagnosis of brain metastasis that was discovered to be a primary CNS pathology, such as primary CNS tumor, abscess, or focus of demyelination, were excluded from the study. To achieve the outcomes of this study, all eligible patients in the five-year study period were entered using non-probability consecutive sampling.Data collection processA data collection sheet containing demographic data such as age and gender, and information pertaining to the primary pathology, multiplicity, and survival outcome was used. The authors have collected their data through the National Guard Hospital's BestCare system in Jeddah.Data analysisData recorded were entered and analyzed using Statistical Package for the Social Sciences (SPSS) Version 23 . Categorical data were computed and presented in frequencies and percentages. Continuous data were used based on normality assessments and were presented in means and standard deviations or medians and quartiles to describe the data depending on distribution. Comparison of these variables was done using independent and dependent samples t-test or Mann-Whitney U test for continuous data, as appropriate, and chi-square test for categorical data. P-values < 0.05 were considered significant. A Kaplan-Meier product limit method was used to estimate survival analysis.Demographic dataA total number of 213 patients were enrolled in this study. Of the sample, 68.1% comprised of females. The mean age of patients was 53.6 \u00b1 15.9 years. The vast majority of cases had breast cancer as their primary pathology (44.1%), followed by lung cancer (22.1%), renal cancer (6.1%), and colorectal cancer (2.8%). Other types of primary cancers that contributed to brain metastasis totaled to 24.9%. Approximately two-thirds (61.9%) of the patients\u2019 imaging results revealed multiplicity, whereas the remaining third (38.1%) had solitary lesions. In regard to survival outcome, 72.3% of all patients were documented to have passed away. The estimated overall survival median after the diagnosis of brain metastasis was six months (95% CI: 5.5-6.5) ; 77.4% (48 out of 62) males were announced deceased, while 69.6% of females (96 out of 138) passed away. The survival median for males specifically was 48 months (95% CI: 4.1-5.5), and females\u2019 median equaled 60 months (95% CI: 5.3-6.7). Time of follow-up for 10 deceased patients was missing; therefore, they were not included in Tables In regard to primary pathology, significant differences p = 0.006) in fatality were shown among\u00a0the five cancer pathologies listed in Tables  in fatalBrain metastasis characterized by multiplicity was an insignificant predictor of increased mortality with a p-value of 0.89. Overall, 70.6% of patients who had multiple metastatic lesions eventually died, and 74.3% of patients with a single metastatic mass died. Patients with multiple metastatic lesions survived for a median of 60 months (95% CI: 5.4-6.6), whereas patients with solitary lesions lived a median of 48 months (95% CI: 4.0-5.5)\u00a0, lung cancer (22.1%), renal cancer (6.1%), and colorectal cancer (2.8%). Given the fact that more than half of our patients were females, breast cancer was the primary pathology at the top of the list. Rastogi et al. reported that lung (68%) was the most common primary pathology site, followed by breast 11%) . Similar% . SimilThe overall survival of patients following their diagnosis of brain metastasis was six months. In contrast with our results, Rastogi et al also reported a median overall survival rate of six months . HoweverThe fatality of patients with brain metastases varied significantly according to the primary pathology. Colorectal cancer resulted in the highest death rates, followed by renal cancer, primary lung cancer, and other unspecified primary cancer. Lung, breast, and renal cancers had an estimated median survival of 60 months; however, colorectal cancer had the shortest survival duration (36 months). In contrast, a study conducted by Berghoff et al. reported that patients with breast cancer had the longest median overall survival duration (eight months), followed by patients with lung cancer and renal cell carcinoma (seven months) and melanoma (five months) . MoreoveWhile breast cancer does not have the highest rate of mortality among patients with brain metastasis, it is accountable for the most cases of total deaths secondary to brain metastasis. In contrast to our results, Rotta et al. mentioned that lung cancer was responsible for the most deaths .LimitationsAlthough the research tackles brain metastases and their association to various factors like primary pathology and gender, there are still limitations faced in the study. For example, our study is based on records of a single institute; its results might not reflect the general population despite its concurrence with the existing literature. The study, albeit setting a foundation for future research, has brushed over the topic in a superficial manner and requires extensive research in the future, such as performing comparative studies between the factors discussed in regard to brain metastases.Brain metastases are a devastating neurological complication of systemic cancer. It leads to significant morbidity and mortality. The incidence of brain metastasis is increasing with the advancement of diagnostic imaging. Various tumors can metastasize to the brain, our study demonstrated the most prevalent primary pathology tumors to result in a brain metastasis to be breast cancer, lung cancer, renal cancer, and colorectal cancer, respectively. Moreover, multiplicity was noted among patients having brain metastasis. We recommend carrying out a nationwide study to better understand the incidence in accordance to geographical and gender differences. We can further expand our research to include other institutes in Saudi Arabia and include important predictors like time from the diagnosis of primary pathology till brain metastasis, disease progression cost, disease progression in the months prior to the patients\u2019 death."}
+{"text": "A new model provides insight into the \u2018how\u2019 and \u2018why\u2019 of wellbeing to better understand the \u2018what\u2019. Informed by evolutionary psychology and neuroscience, it proposes that systems for adaptive motivation underpin experiential and reflective wellbeing. The model proposes that the brain learns to predict situations, and errors arise between the predictions and experience. These prediction errors drive emotional experience, learning, motivation, decision-making, and the formation of wellbeing-relevant memories. The model differentiates four layers of wellbeing: objective, experiential, reflective, and narrative, which relate to the model in different ways. Constituents of wellbeing, human motives, and specific emotions integrate into the model. A simple computational implementation of the model reproduced several established wellbeing phenomena, including: the greater frequency of pleasant to unpleasant emotions, the stronger emotional salience of unpleasant emotions, hedonic adaptation to changes in circumstances, heritable influences on wellbeing, and affective forecasting errors. It highlights the importance of individual differences, and implies that high wellbeing will correlate with the experience of infrequent, routine, and predictable avoidance cues and frequent, varied, and novel approach cues. The model suggests that wellbeing arises directly from a system for adaptive motivation. This system functions like a mental dashboard that calls attention to situational changes and motivates the kinds of behaviours that gave humans a relative advantage in their ancestral environment. The model offers a set of fundamental principles and processes that may underlie diverse conceptualisations of wellbeing. Functional definitions have potential to ground the many different conceptualisations of wellbeing within basic processes that transcend their differences.Different individuals, groups, literatures, and cultures conceptualise wellbeing differently. There are many al terms ,2,3. Thetituents ,5,6. ImaPsychological approaches have sketched coarse outlines of the \u2018how\u2019 and \u2018why\u2019 of wellbeing based on psychological theories and research findings ,8. NeuroTo address this gap in wellbeing theory, this paper will put forward a model that attempts to capture important features of how and why wellbeing functions, in which each approach has a place and scope to refine details. It will first introduce the model from a theoretical perspective, before integrating existing literature into the model. Following sections will describe a numerical implementation and qualitative results used to investigate whether the model has potential to reproduce important characteristics of wellbeing. The results will be discussed in the context of empirically researched wellbeing phenomena to explore the implications of the model and how it aids in understanding the nature of wellbeing.A fundamental attribute of humans, and indeed organisms in general, is that they have agency. They can alter their fitness through their behaviour. One behaviour might find a new source of food to increase fitness, while a different behaviour may result in an injury that decreases it. These situations change fitness in different ways, and behaviour can influence which situation eventuates. Moreover, humans can change their environment to increase opportunities and reduce threats (niche-construction), and this process may play an important role in wellbeing ,19.The fundamental challenge of having agency is in using it effectively with limited resources of time and energy. The complexity and difficulty of maximizing fitness through agency within a complex environment is hard to overstate. The challenge inherently concerns motivation, since it guides behaviour ,21. MotiSituations offer a very large number of potential stimuli, and adaptive behaviours must be situation-specific. With a limited capacity to process these stimuli, humans can only give cognitive resources to a subset of them. If left to chance, individuals might miss important cues. So, certain genetic and non-genetic predispositions could give individuals an advantage.The model assumes individuals develop predispositions to attend to and process particular stimuli in certain ways, which result in certain neural patterns of activity. The brain includes a range of functionally specialised structures. For example, lower-order processes operate quickly and effortlessly to distil particular sets of physical stimuli into more compact representations . Other pcues. Situations elicit certain cues depending on how these neural patterns have developed in the individual under heritable influences. Functionally, cues serve as the detectors of fitness-relevant physical signals, situation characteristics, or types of situations [This paper will term these neural patterns tuations . Stimulituations .Cues function as meaningful inputs for motivational processes, and the quality of motivation depends on the quality of these inputs. Evolutionary psychology suggests that selection pressure applies to them. Individuals who generate higher quality cues would have a reproductive advantage from an evolutionary perspective. The cues most useful as motivational inputs will relate to situations that either increase or decrease fitness, so these are likely to be what adapted individuals attend to.Cues can be separated into two types. Outcome cues correspond with increases or decreases in fitness that are not contingent on behaviour. Predictive cues correspond with possible future changes in fitness that are contingent on situation-specific responses . Both cue types provide useful signals for motivation.cue value) that determines how they subsequently influence motivation. Such values distinguish affective phenomena from other non-affective phenomena [Approach cues (positive) increase the likelihood of behaviours that make those cues more likely to reoccur, while avoidance cues (negative) do the opposite.The model assumes that cues have a neurological value  in heuristic choice-making processes to guide adaptive behaviour . NeuroloThe model proposes that a hierarchy of goals emerges as mental models of the world develop increasing levels of abstraction and complexity. Base-level goals correspond with the simplest of choices. Such goals relate closely to particular cues, and can be informed directly by preference sensing. Lower-order goals become the building blocks of higher-order goals. Very high-order goals, such as \u201cget a promotion\u201d, rest on a hierarchy of lower-order goals, making them more detached from base-level cues and preferences. The processes and outcomes of these high-order goals are more complex. Thus, achieving some high-order goals may change the cues experienced, but achieving others may not.Different combinations of cues may elicit impulses toward multiple incompatible behaviours. Thus, individuals must often suppress impulses for competing behaviours. Based on neuroscientific and psychological research ,48, the This conflict resolution function may be critical in bringing together many of the functionally specialised processes within the brain. Many distinct brain processes could be independently involved in the generation of cues, cue value, prediction errors, and learning processes . The conResearch in neuroscience has shown that prediction errors play an important role in episodic memory formation ,50,51. SNeuroscience also suggests that memories decay, which may ensure the most useful information is retained. The decay involves several processes, including interference from new memories and a process of \u2018active forgetting\u2019 ,58. MoreThe Adaptive Motivation Model serves as a lens through which to understand the nature of wellbeing. It suggests four related layers of wellbeing: objective, experiential, reflective, and narrative. Each layer is deeper and more complex than the previous ones, as summarised in First, objective wellbeing depends on the recent situations and behaviours of the individual as objectively assessed, not on any internal processes. One can assign subjective values to situations within the context of a particular value system , which the individual may or may not share. When assessed as a whole, these values constitute a measure of objective wellbeing, such as observed quality of life.want them. On the other hand, cues that prompt negative errors motivate the individual to not want them. This differentiation may form the basis for a subjective significance of the cues, such as positive or negative, good or bad, and so on.Second, experiential wellbeing is the moment-by-moment experience of psychological affect that prediction errors elicit, along with their emotional significance. Cues that prompt positive errors motivate the individual to Reflective wellbeing is constructed consciously from readily recallable memory representations, with the most recent memories and those associated with the strongest emotion tending to dominate ,65. The Finally, narrative wellbeing relates to the cognitive significance of narratives and beliefs developed from past experiences. It relates to the cognitive aspect of subjective wellbeing and an assessment of one\u2019s own life satisfaction. Individuals frame wellbeing-relevant memories within a more cohesive narrative that emphasises certain memories over others and infuses them with meaning. A hierarchy of narratives may emerge from episodic memories, with higher-level narratives allowing the influence of past events to persist for longer periods . ConsequThe same set of memories can serve as the building blocks for many different narratives that differ in their subjective qualities. Hence, narrative wellbeing is tied to experiences more loosely than the lower wellbeing layers. From the perspective of wellbeing, events from the more distant past have particular relevance to beliefs and evaluations that relate to the self.Eudaimonic wellbeing  relates The suggested aspects of wellbeing have relevance to each layer in different ways. For example, a meaningful event can be observed objectively (objective layer), it often elicits emotions , it can be \u2018re-lived\u2019 in the near term through recall (reflective), and it may influence self-narratives and beliefs (narrative). Many higher-level cues impact on wellbeing at all four levels. However, lower-level cues that are more sensory in nature relate more strongly to the experiential layer, since they may be quickly forgotten or not incorporated into narratives.A good model integrates with existing literature. This section will explore how the Adaptive Motivation Model integrates with literature through three lenses: existing terms that relate to wellbeing, human motives, and specific cues and emotional experiences.The model suggests the prediction errors that underlie wellbeing would have guided humans in the ancestral environment to increase and maintain fitness by shaping their motivations. So, the first lens connects fitness with quantitative definitions of wellbeing.Based on the reviews of Hone et al. , Longo eThe model suggests positive and negative emotions are intimately linked with changes in fitness and prompted by many different kinds of cues. The first seven aspects organise these kinds of cues into thematic groups. Cues may relate to more than one aspect, and the aspects listed here may not be comprehensive. The eighth aspect, positive emotion, is general and relates to the experiential and reflective layers of wellbeing. Cues within the first seven aspects often elicit positive emotions, but the positive emotion aspect could also include any cues that do not fit within those first seven aspects. The final aspect, positive narrative, involves self-referential narratives and beliefs. It relates to the narrative layer of wellbeing. The associations between terms in this last aspect and fitness, if present, seem more indirect.The aspects in If motivational processes underlie wellbeing, strong links might exist between the aspects in For some motives, the connection with wellbeing only becomes clear by shifting the reference frame to receiving the behaviour, such as control of others or dominance. Motives concerned with positive expectancy often involve environmental factors such as safety and security. Environmental factors impact several wellbeing aspects, however.Significantly, motives relating to mating and resources did not fit well with the seven main wellbeing aspects in pywellbeing package at https://pypi.org/ and https://github.com/ (accessed 29 August 2021). The implementation required no external data sources. Since all variables were represented abstractly as numerical values, they did not require operationalisation.This section outlines a simple computational implementation of the model see the . The purThe numerical implementation simulated how individuals behaved, learned, and reproduced. It rested on a set of independent situations, which differed only in their frequency and how they influenced fitness. Situations that could slightly influence fitness occurred often, while those that could greatly influence it occurred rarely. The choice between two behaviours could avert the outcome of a situation. Individuals learned which choices to make through a numerical representation of the Adaptive Motivation Model. The implementation needed no particulars of individuals, situations, or cues, as they were generic. Starting with a \u2018naive\u2019 generation, the simulation allowed individuals in each generation to learn and make motivated choices over many periods, which led to certain levels of fitness and wellbeing. Each subsequent generation was bred from only the individuals with higher relative fitness, which simulated natural selection pressure. Adaptive motivational predispositions could thus develop over successive generations.The numerical simulation was based around a set of Here, Instincts and reinforcement learning determined the likelihood of two behaviours in response to predictive cues elicited by each situation. One behaviour nullified the situation so there was no outcome cue and no impact on fitness, while the alternative behaviour allowed the outcome to occur and fitness was changed by The probability of the former behaviour was thus Instinct value, For each situation at each period, prediction error, Based on standard approaches to update predicted values , the weiCalculation of effort values that governed planned control was as follows. Effort for each situation, Effort reallocation by each individual at each time period, A population of Reflective wellbeing for individual The nature of this model precluded setting model parameters using empirical data. Thus, model parameters were set manually to ensure the model performed as intended. If pywellbeing package. For the purpose of investigating whether the model may offer insight into wellbeing, the qualitative patterns are more important than the particular values.Selected results of the numerical simulation are described below. More detailed results can be reproduced using the Selection pressure caused the fitness of individuals in each generation to increase significantly and remain steadily high after the 50th generation see a. The inThe increases in population fitness a were a Population means for instincts changed from the near-zero values of the initial generation shown in If prediction errors elicit emotions of corresponding strength, negative cues were significantly stronger than positive cues by 2\u20133 times for relatively common cues, as shown in The numerical model was also used to test the effects of environmental changes. After 200 normal periods, the adapted population was subject to a novel environment in which the likelihood of experiencing a particular cue was much higher. Learning processes for reinforcement learning and planned control processes were disabled at the start of the change to prevent behavioural shifts from influencing the result.d Corbit . These dImportantly, while adaptation restored wellbeing to almost the original level, a residual difference remained. This residual difference was a consequence of the decay processes included in the model. Interestingly, individuals tended to adapt to approach cues more quickly and more fully than avoidance cues.Once the change was reversed after 40 periods, wellbeing levels did not immediately return to baseline levels. After an avoidance cue became much more frequent, the return to normal resulted in a period of slightly higher levels of wellbeing compared to baseline. Approach cues showed similar but opposite effects.This paper presents a model of the \u2018how\u2019 and \u2018why\u2019 of wellbeing, based on considerations from evolutionary psychology and neuroscience, to understand what wellbeing is more deeply. According to this model, experiential wellbeing arises as a consequence of motivational processes to change behaviour adaptively by detecting errors between predicted cues and experienced cues. Memories of situations that elicit significant prediction errors then provide a basis for reflective and narrative wellbeing.Several qualitative results of the numerical implementation correspond with existing research findings. Collectively, they suggest the model may indeed provide a useful understanding of what wellbeing is and why it operates how it does.First, the model suggests that modern humans, as an adapted population, will experience approach cues more frequently than avoidance cues through agency, as Second, the model predicts individuals will feel stronger affect for avoidance cues than for approach cues see , which cThird, the model predicts several hedonic adaptation phenomena, as Fourth, the model suggests that to individuals with the highest wellbeing, avoidance cues will seem infrequent, routine, and predictable yet approach cues will seem frequent, varied, and novel. Experiences where approach cues are frequent yet unpredictable could potentially arise in positive social relationships, for example, where others initiate positive interactions. Flow experiences could also provide a source of varied approach cues, since the nature of the experience often has novel elements. Experimental evidence supports the view that novel or varied positive experiences correspond with higher wellbeing ,94. A laFifth, the model implies that wellbeing itself will have heritable variance, since prediction errors are based on heritable cue values. Indeed, several studies have shown wellbeing to have a heritable component ,97. Morecurrent situation, not based on the prediction errors those cues will elicit once the individuals are in those future situations. If a choice changes the frequencies at which cues occur, the brain will learn to predict them (hedonic adaptation). Thus, their affective impact in the future situations will differ from their predicted affective impact in the present. Several researchers have found these affective forecasting errors occur and have proposed similar mechanisms [Sixth, the model suggests that individuals will make systematic errors in choices intended to maximise their happiness. In the model, individuals sense preferences based on how the cues elicited by simulated outcomes compare with their chanisms ,101. PerFinally, the model has implications for understanding the relationship between goal achievement and wellbeing. It suggests that goal achievement itself does not have a commanding influence on wellbeing. Rather, wellbeing depends on how cues and their predictions change both during goal pursuit and subsequently. Achieving a major goal after a stressful and highly uncertain process may feel temporarily euphoric, and the events lend themselves to a dramatic, triumphant, and memorable narrative. Yet, achieving the very same goal after a calm and predictable process may feel anticlimactic. Frequent and varied approach cues  during the project could end with it and even add a subjectively negative aspect to accomplishing a valued milestone.The model suggests the same cues may influence wellbeing differently between individuals. Cue values will differ between individuals, as the ranges in Different past experiences may result in differences in predicted cue values, which could cause variability in prediction errors. Increasing the frequency of a particular cue by once daily may significantly change wellbeing for an individual who seldom experiences that cue. Yet, the same increase in frequency is unlikely to change wellbeing much for an individual who already experiences it many times a day. The ways in which particular cues influence wellbeing will thus vary across different social, economic, and demographic contexts.want to increase or decrease the frequency of the very cues that underlie our wellbeing. Like indicators on a vehicle dashboard, the value of these indicators lies in their reliable correlation with outcomes we implicitly care about. The model suggests those outcomes involve changes in fitness in our ancestral environment, and wellbeing indicators function to motivate us toward the kinds of behaviours that gave our ancestors a relative advantage.The model suggests that wellbeing arises directly from a system for adaptive motivation. This system functions like a mental dashboard that calls attention to changes in the cues that motivate us\u2014the neural signals that guide our choices and behaviour. A complex developmental cascade makes us According to the adaptive motivation perspective, the brain learns to predict the cues elicited by situations. Differences between experience and prediction generate emotion, drive learning, and guide motivated behaviour. Recent memory representations of these differences form the basis for reflective wellbeing. Narrative wellbeing relates to selected memories over a longer time period that often concern the self, so changes in narrative may significantly change self-evaluation.The cues that underlie reflective wellbeing are based in the environment, culture, and challenges of our ancestors. Many cues from that environment remain relevant today. However, significant discrepancies exist between modern and ancestral environments that present challenges for wellbeing ,103. TheAccording to the model, selection pressures have led to modern humans sharing similar predispositions for cues and cue values. This commonality may in part explain why wellbeing is a meaningful construct to measure across all four levels. Researchers find meaningful correlations in how shared cues influence emotion and wellbeing. However, some cues may be important for only smaller subsets of the population, and these cues could potentially relate to concepts not well covered by common measures.Given the complexity of wellbeing, any parsimonious model will by necessity omit nuances and fail to capture details. The current model cannot capture many details of how perception, motivation, learning, memory, and wellbeing function. Thus, it does not replace detailed research.As a model in its infancy, the numerical implementation serves only as an illustration of wellbeing dynamics. Research is needed to refine and validate the processes and parameters of the model. The model could also benefit from more sophisticated neuroscience-based models for attention, learning, and decision-making. For example, approach and avoidance cues could be dealt with in different ways to better represent the different neural subsystems involved.Future research could identify cues that act as input signals to wellbeing. This could improve understanding of their relationships with different layers of wellbeing. Further work could also improve understanding of how particular cues relate to wellbeing narratives and their psychological significance.This paper introduced the Adaptive Motivation Model of wellbeing that draws on evolutionary psychology and neuroscience. A simple numerical implementation of this model produced several wellbeing phenomena that find support within the existing wellbeing literature. These include a greater frequency of positive affect to negative affect, the more powerful emotional salience of negative emotions, hedonic adaptation, effects of variety and novelty on wellbeing, affective forecasting errors, and a genetic influence on wellbeing. The model also suggests how individual differences may play an important role in wellbeing, since the same cues will influence individuals differently. It represents a step toward a parsimonious explanation for the \u2018how\u2019 and \u2018why\u2019 of wellbeing, as a way to better understand the \u2018what\u2019. It suggests that wellbeing arises directly from specific cues used by the motivational system to guide adaptive behaviour. The Adaptive Motivation Model invites new research into specific low-level cues that generate motivational preferences and wellbeing-relevant memories, and further refinements of the model may be worthwhile."}
+{"text": "Mucormycosis is a rare but serious opportunistic fungal infection that occurs in immunocompromised individuals, especially those with diabetic ketoacidosis. Presently, early diagnosis of the disease remains a challenge for clinicians.The patient, a 68-year-old woman with type 2 diabetes mellitus, was admitted with paroxic sharp pain in the left upper abdomen. CT imaging revealed a patchy hypodense shadow of the spleen with wedge-shaped changes. The patient was not considered early for fungal infection. The diagnosis of spleen mucormycosis was not confirmed until pathological biopsy after splenectomy. After surgery, blood glucose level was controlled, acidosis was corrected, and antifungal therapy was effective.We report here, for the first time ever, a case of isolated splenic mucormycosis secondary to diabetic ketoacidosis that was diagnosed and treated with antifungal drugs and splenectomy. Following splenectomy, the presence of splenic mucormycosis was confirmed when characteristic mycelia were observed in a tissue biopsy. As the location of any fungal infection is extremely relevant for treatment options and prognoses, early diagnosis and clinical intervention can greatly affect outcomes and prognoses for patients. Mucormycosis is a rare invasive fungal infection that occurs mainly as a secondary condition in individuals with other underlying diseases (particularly diabetic ketoacidosis) that cause immune deficiency . Based o2)\u2009<\u200910 mmHg, bicarbonate (HCO3)\u2009<\u200910 mmol/L, and base excess \u2212\u200933.8. Laboratory findings suggested hyperglycaemia with glycosuria and ketoacidosis. An abdominal computed tomography (CT) imaging revealed a patchy hypodense shadow of the spleen with wedge-shaped changes , and coagulation function tests reported the following: fibrinogen level 6.36\u00a0g/L, activated partial thromboplastin time 22.50\u00a0s, D-dimer level 2.28\u00a0mg/L, and fibrin degradation products 6.10\u00a0mg/L. Arterial blood gas analysis revealed a state of metabolic acidosis: pH 6.80, partial pressure of carbon dioxide in arterial blood . After 12\u00a0h of intravenous infusion of insulin (blood glucose was measured every hour), levels of blood ketone body and urine ketone body turned negative for three consecutive times, the intravenous infusion of insulin was stopped, and the blood glucose was controlled by insulin pump, with close monitoring via blood gas analysis until the acid-base balance was achieved.After discharge, metformin was prescribed regularly to control blood glucose. The patient was followed up for 2 years without relapse.Mucormycosis is a life-threatening and angio-invasive fungal infection that often occurs secondary to diabetic ketoacidosis. Thus far, no specific clinical symptoms and ancillary tests have been identified for this condition, which makes the clinical diagnosis of mucormycosis very difficult.The occurrence of isolated splenic mucormycosis is extremely rare, as till now, only five cases of this condition have been reported \u20137 Table. The undAs of now, no cases of isolated splenic mucormycosis secondary to diabetic ketoacidosis have been reported. In Roden\u2019s review of 929 cases of mucormycosis , diabeteThe clinical manifestations of splenic mucormycosis are nonspecific  and may As of now, fungal cultures, histopathological biopsies and molecular biology-based tools may be used to confirm a diagnosis for mucormycosis. The fungal culture is highly specific, but low sensitivity results in false negatives in more than half the cases of mucormycosis infections. Histopathological biopsies can identify fungal infections more clearly, while also allowing visualisation of vascular invasion by the fungus .An important hallmark of mucormycosis is vascular invasion and extensive tissue infarction, with the infected organ/area often showing intense granulomatous inflammation  . The infThe fungal hyphae are wide (5\u201320\u00a0\u03bcm), thin-walled, and irregularly ribboned with little separation (pauciseptate), and branch irregularly at no fixed angle; in cross-sections, the fungus appears cystic, and spores are rarely seen . HaematoIn this case, the lungs, nose, brain, or skin were found to be free of mucormycosis. Since the spleen is an intra-abdominal parenchymal organ, the diagnosis of mucormycosis splenicum was confirmed mainly through histopathological biopsy. Splenic mucormycosis is mainly diagnosed by comparing biopsies of infected tissue with other splenic tissue infected by other fungal agents such as Aspergillus and Candida; Candida hyphae are thin (2\u20134\u00a0\u03bcm in diameter) and often bead-like , whereasIn this case, the splenic mucormycosis was treated through surgical splenectomy and administration of an antifungal agent (amphotericin B), along with symptomatic treatment . However, some characteristics of the patients might have also influenced the treatment decision; for example, the patient in this case was older and had a history of diabetes for many years. During the treatment, a large amount of fluid rehydration is likely to induce acute left heart failure, which is life-threatening . Since mIn conclusion, we report here, the first known case of isolated splenic mucormycosis occurring secondary to diabetic ketoacidosis. The diagnosis was confirmed by microscopy of the splenic biopsy tissue, in which characteristic mycelia were observed. The patient was treated with an antifungal agent (amphotericin B) after surgically removing the spleen, and significant improvement was seen. This case serves as an important reference for the early diagnosis and treatment of isolated splenic mucormycosis associated with diabetic ketoacidosis."}
+{"text": "Base excess (BE) represents an increase or decrease of alkali reserves in plasma to diagnose acid-base disorders, independent of respiratory factors. Current findings about the prognostic value of BE on mortality of patients with acute myocardial infarction (AMI) are still unclear. The purpose of this study was to explore the prognostic significance of BE for short-term all-cause mortality in patients with AMI.A total of 2,465 patients diagnosed with AMI in the intensive care unit from the Medical Information Mart for Intensive Care III (MIMIC-III) database were included in our study, and we explored the association of BE with 28-day and 90-day all-cause mortality using Cox regression analysis. We also used restricted cubic splines (RCS) to evaluate the relationship between BE and hazard ratio (HR). The primary outcomes were 28-day and 90-day all-cause mortality.2), and patients had the highest mortality in the group which had low BE (< 3.5 mEq/L) and high PaCO2 (> 45 mmHg) compared with other groups.When stratified according to quantiles, low BE levels at admission were strongly associated with higher 28-day and 90-day all-cause mortality. Multivariable Cox proportional hazard models revealed that low BE was an independent risk factor of 28-day all-cause mortality  and 90-day all-cause mortality , even after adjustment for significant prognostic covariates. The results were also consistent in subgroup analysis. RCS revealed an \u201cL-type\u201d relationship between BE and 28-day and 90-day all-cause mortality, as well as adjusting for confounding variables. Meanwhile, Kaplan\u2013Meier survival curves were stratified by combining BE with carbon dioxide partial pressure (PaCOOur study revealed that low BE was significantly associated with 28-day and 90-day mortality in patients with AMI and indicated the value of stratifying the mortality risk of patients with AMI by BE. The most common cause of cardiovascular disease (CVD) mortality worldwide is acute myocardial infarction (AMI), which is characterized by myocardial cell death caused by prolonged ischemia. More than 2.4 million people in the USA die annually from it, more than 4 million people in Europe and Northern Asia, and about one-third of people in developed countries die from it . Althoug2), and lactate levels  test is a commonly ordered test in intensive care units (ICUs) that also analyses pH and blood gases in addition to electrolytes . Accordie levels . Among pe levels . Thus, se levels \u20138. For ee levels . In a ree levels . Howeverwith AHF . It is wIn previous research, it was found that high BE, but not low BE, was an independent predictor of long-term mortality in patients with AHF , indicatOur study is a retrospective analysis, in which data are extracted from a vast critical care database named Medical Information Mart for Intensive Care III (MIMIC III). The MIMIC III database is a free and large public database that comprises de-identified and definitional health-related data, which contains over 40,000 patients admitted to intensive care units (ICU) of the Beth Israel Deaconess Medical Center  between 2001 and 2012  codes. There were 192 patients who were under 18 years old or with an incorrect age and 520 patients without the result of BE. Thus, a total of 2,465 patients with AMI were ultimately enrolled in our study.2, PaCO2, bicarbonate (HCO3\u2013), BE, AG, lactate, hemoglobin, platelet (PLT), white blood cell (WBC), albumin (ALB), urea nitrogen (BUN), creatinine (Scr), glucose, sodium, potassium, percutaneous coronary intervention (PCI), percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass grafting (CABG), Simplified Acute Physiology Score II (SAPS II), and Sequential Organ Failure Assessment (SOFA) score; and (6) oral medication, including aspirin, clopidogrel, beta blockers, diuretics, digitalis, and statin. All blood biochemical variables were the first measurement after the patient\u2019s admission to the hospital before treatment.All variables were extracted from the MIMIC III database using Structured Query Language (SQL) with PostgreSQL (version 9.6). The variables in our study included (1) physical characters, including age, gender, and body mass index (BMI); (2) types of hospital admission, including elective, emergency, and urgent; (3) past history, including hypertension, diabetes, dyslipidemia, atrial fibrillation (AF), acute kidney injury (AKI), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), acute respiratory distress syndrome (ARDS), and sepsis; (4) vital signs, including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), heart rate (HR), respiratory rate (RR), and temperature (T); (5) laboratory data, including pH, SpORecords from the Social Security Death Index provided information on survivorship . Notably, 28-day and 90-day all-cause mortality after the date of ICU admission were analyzed in our study.P < 0.05 in the univariate Cox proportional-hazards model were entered into separate multivariate models for 28-day and 90-day all-cause mortality: model 1, crude; model 2, included age, gender, SBP, and DBP; model 3, included variables in model 2 and hypertension, AF, COPD, AKI, sepsis, and CHF; model 4, included variables in model 3 and aspirin, clopidogrel, beta-blockers, diuretics, digitalis, statin, PCI, and CABG; model 5, included variables in model 4 and sodium, potassium, ALB, BUN, Scr, AG, and SpO2. Meanwhile, restricted cubic splines (RCS) were used to separately explore the relationship between BE and hazard ratio (HR) of 28-day and 90-day mortality. The cumulative incidence of 28-day and 90-day all-cause mortality was presented using the Kaplan-Meier curve. Additionally, Kaplan-Meier curves were also generated for BE combined with PaCO2 as the respiratory factor. BE cutoff values (\u20133.5 mEq/L) were determined by receiver operating characteristic (ROC) analysis using the Youden index for 28-day all-cause mortality. To explore the link between admission BE values (modeled as continuous variables) and the risk of 28 and 90-day all-cause mortality, RCS was used. All analyses were performed using R . All tests were two-sided, and P < 0.05 was considered statistically significant.Variables in the categorical form are presented as numbers (percentages) and variables in continuous form as mean \u00b1 standard deviation if the distribution is normally distributed and median (interquartile range) otherwise. Continuous variables were analyzed using analysis of variance or Kruskal-Wallis tests to determine baseline differences among groups stratified by BE, and the chi-squared test or Fisher\u2019s exact test was used for categorical variables. We also examined the relationship between BE and the outcomes  using both univariate and multivariate Cox proportional-hazards models. Variables with 2, PaCO2, HCO3\u2013, PLT, and ALB as well as the rate of hypertension, diabetes, and invasive ventilation.In total, 2,465 patients with AMI were included in our study, among which 1,430 (58.0%), 677 (27.5%), and 358 (14.5%) patients were classified as having normal BE, low BE, and high BE, respectively. The median age was 67 years and 1647 (67.9%) patients were male. Baseline clinical characteristics of patients stratified by BE are shown in The unadjusted Cox proportional hazard regression model showed that the low BE group, but not a high BE group, was an independent determinant of the risk of 28-day mortality  . Despite2, as well as the use of aspirin, clopidogrel, beta-blockers, diuretics, digitalis, statin, PCI, and CABG, there was still an \u201cL-type\u201d relationship between BE and risk of 28-day all-cause mortality  were determined by ROC analysis for 28-day all-cause mortality using the Youden index (2 are shown in 2 level was associated with the highest 28-day all-cause mortality (To further determine the relationship between BE and mortality, we added PaCOen index . Kaplan\u2013ortality  and the ortality  among thOur retrospective study of 2,456 patients with AMI showed that low BE was significantly associated with increased 28-day and 90-day all-cause mortality. The correlations between low BE levels and risk of cardiovascular events were independent of other cardiovascular risk factors, and they remained significantly stable in subgroup analyses. In contrast, high BE had no correlation to the mortality of patients with AMI. Moreover, an \u201cL-type\u201d association between BE and 28-day and 90-day all-cause mortality was found. These results indicated meaningful predictive implications in the clinical practice of BE.2, and PaCO2 had no association with all-cause mortality in patients with HF (Several studies have shown that BE is one of the most important tools for determining the severity of illness in acute care settings , 13, 14. with HF . However with HF . However with HF . Our finThere are several factors affecting BE concentrations and many possible reasons responsible for the difference between our results and others. Previous literature showed that the acid-base balance was first identified by pH. Nevertheless, pH was affected by metabolic and respiratory status. To stratify risk based on alkalemia or acidemia, only patients with those conditions were further investigated . MeanwhiMetabolic acidosis is divided into high AG metabolic acidosis and hyperchloremic or normal AG metabolic acidosis. In addition to lactic acidosis and ketoacidosis, metabolic acidosis could be caused by ethylene glycol, methanol, and salicylate intoxication. Similarly, hyperchloremic metabolic acidosis is most commonly caused by renal tubular acidosis, gastrointestinal bicarbonate depletion, drug-induced hyperkalemia, early renal failure, and acid infusion. In patients with AMI, falling cardiac output combined with arterial hypoxemia causes tissue hypoxia, metabolic acidosis, and a drop in plasma bicarbonate due to lactic acid accumulation. Acidosis of the metabolism increases with disease severity and is an important cause of death. The build-up of acidic metabolites during cardiac ischemia results in a drop in intracellular and extracellular pH, reaching as low as 6.0\u20136.5. Ischemic injury is exacerbated by resulting tissue acidosis, which negatively affects cardiac function . In an e2. Hypercapnia can often be found in patients with AMI requiring intubation, and it is always associated with severe lung diseases or heart disease (2 was not an independent variable in our study. When we combined the BE with PaCO2 to explore the prognosis of patients with AMI, the predictive efficiency would be much better. Therefore, our results could indicate that PaCO2 would be useful for risk stratification when in conjunction with BE.Furthermore, our study revealed that the patients with coexisting metabolic acidosis and respiratory acidosis could have the worst prognosis among the four groups which had different BE levels and PaCO disease , 29. Not2. BE, as an easily obtained and important marker on admission for critically ill patients, could be used as a reliable predictor of prognosis in patients with AMI.Our study revealed that low BE was significantly associated with 28 and 90-day mortality in patients with AMI and indicated the value of stratifying the mortality risk of patients with AMI by BE, especially when combined with PaCOOur study has some limitations. First, our study is an observational study, and we cannot determine the causal relationship between BE and the mortality of patients with AMI, so there needs a cohort study to explore the mechanism. Second, AMI-related risk factors were included as much as possible in our study, such as comorbidities and laboratory examinations. However, due to the limitations of the data, other residual confounding risk factors may not be included in the logistic model. So more detailed clinical cohort studies are still needed to support our study conclusions. Third, this study was limited to short-term outcomes, and data on the relationship between BE level and long-term outcomes of patients with AMI are still missing.https://mimic.mit.edu/docs/gettingstarted/.Publicly available datasets were analyzed in this study. This data can be found here: CL, ZD, and GT designed the study. CL, ZD, TZ, QL, and DH analyzed and interpreted the data. CL and ZD drafted the manuscript. CL, ZD, TZ, DW, BW, PG, and GT revised the manuscript. All authors gave final approval of the final version to be published."}
+{"text": "PLAGL2 amplification; the remaining 27 CNS tumors were essentially immunonegative (<0.05% positive). Among ETMR, PHOX2B expression was observed in a small overall proportion (0.04%\u20134.94%) of neoplastic cells but focally reached up to 39% in 1\u2009mm \u2018hot spot\u2019 areas. In the PLAGL2\u2010amplified case, 0.09% of the total neoplastic population was immunoreactive, with 0.53% in the \u2018hot spot\u2019 area. Care should be taken in interpreting PHOX2B immunopositivity in a differential diagnosis that includes metastatic neuroblastoma and CNS tumors; focal or patchy expression should not be considered definitively diagnostic of metastatic peripheral neuroblastoma.Paired\u2010like homeobox 2b (PHOX2B) is an established immunomarker for peripheral neuroblastoma and autonomic nervous system cells. We aimed to evaluate the utility of PHOX2B immunostaining in central nervous system (CNS) tumors with embryonal morphology. Fifty\u2010one tumors were stained with PHOX2B and submitted for whole slide image analysis: 35 CNS tumors with embryonal morphology ; and 16 peripheral neuroblastomas were included for comparison. Diffuse nuclear immunopositivity was observed in all (16/16) neuroblastomas (primary and metastatic). Among CNS embryonal tumors, focal immunoreactivity for PHOX2B was observed in most (5/7) embryonal tumors with multilayered rosettes (ETMR) and a single high\u2010grade neuroepithelial tumor (HGNET) with  ATRTatypical teratoid rhabdoid tumorsCHLAChildren's Hospital Los AngelesCICcapicua transcriptional repressorCMAchromosomal microarray analysisCNScentral nervous systemEFTEwing sarcoma family tumorEGFRepidermal growth factor receptorETembryonal tumorETANTRembryonal tumor with abundant neuropil and true rosettesETMRembryonal tumors with multilayered rosettesFOXR2forkhead box R2HGNEThigh\u2010grade neuroepithelial tumorNB FOXR2FOXR2 activationneuroblastomas with NECnot elsewhere classifiedNOSnot otherwise specifiedPHOX2Bpaired\u2010like homeobox 2bPNETprimitive neuroectodermal tumorNeurocytic and ganglionic differentiation is a common feature among central nervous system (CNS) embryonal tumors and gliomas.PHOX2B gene is a paired\u2010like homeobox gene which maps to 4p13 and encodes a transcription factor important for neural crest development and differentiation to sympathetic neurons.The This study was approved by the Institutional Review Board at Children's Hospital Los Angeles (CHLA), with a waiver of patient consent. The CHLA archives were searched for tumors originally diagnosed as either primitive neuroectodermal tumor (PNET) or CNS embryonal tumor at the time of initial review. The integrated diagnoses of these cases incorporated findings of subsequent molecular testing, in some cases changing the final assigned category of tumor. Orthogonal molecular testing results available for the cases included a mixture of next generation sequencing of DNA and RNA with the OncoKids\u00ae cancer panel, chromosomal microarray analysis (CMA), and clinically validated whole genome DNA methylation array with molecular classification,https://github.com/a-dev-walker/CentroidParser. Results of automated analysis were manually reviewed to ensure true nuclear positivity and ensure against artifactual false positive signals.Quantification of percent positivity was performed using whole slide image analysis. Each digital slide was visually inspected. Areas of artifactual positivity  were excluded from the region of analysis. Overall slide positivity was calculated, and for each slide that had an overall positivity above 0.05%, a 1\u2009mm \u2018hot spot\u2019 was computed using the image analysis tool Qupath in conjunction with a custom\u2010made Python script.FOXR2 activation (CNS NB FOXR2), one CNS tumor with BCL6 Corepressor (BCOR) internal tandem duplication, and two CNS embryonal tumors not elsewhere classified (NEC) ); one astroblastoma, MN1\u2010altered; two cerebral gliomas with H3\u20103A G34R mutation; one pediatric\u2010type high\u2010grade glioma with MYCN amplification; and 16 peripheral neuroblastomas .The final study cohort included 51 total tumor cases  pattern. All five ETANTR pattern ETMR cases showed at least focal immunostaining with anti\u2010LIN28 antibody, gain of chromosome 2 and the characteristic gain or amplification of 19q13.42 that includes the micro RNA (miRNA) cluster referred to as C19MC. The remaining two cases of ETMR (Cases 2 and 6) showed histologic features of medulloepithelioma and ependymoblastoma respectively and had focal immunoreactivity with anti\u2010LIN28 antibody.EGFR, MDM4, and MYCN, as described in previous work.H3\u20103A G34R mutation was confirmed by immunohistochemistry and sequencing in Cases 16 and 17. Diagnosis of Case 15 as astroblastoma, MN1\u2010altered, was based on copy number alterations consistent with MN1::BEND2 fusion and an aligned DNA methylation profile. The diagnosis of CNS tumor with BCOR internal tandem duplication (ITD) was based on the morphological features of high\u2010grade astrocytic neoplasm and the detection of BCOR ITD by fragment analysis.The included four glioma cases were initially diagnosed as CNS PNET and were revised after molecular testing confirmed their glial diagnoses. Specifically, CMA of Case 9 showed gain of chromosome 7 and amplifications of strong clinical significance in PLAGL2 amplification (Case 8) as demonstrated by chromosomal microarray and an aligned methylation profile with the recently added category of \u2018HGNET with PLAG\u2010family amplification\u2019 from v12.3 of the DKFZ brain classifier accessible at molecularneuropathology.org.The diagnoses of three cases of CNS NB FOXR2 were based on characteristic copy number alterations (gain of 1q and loss of 16q) as well as aligned DNA methylation profiles. One of the cases diagnosed as CNS embryonal tumor NEC had a For comparative analysis, classic cases of ATRT, medulloblastoma, and pineoblastoma were included in the cohort. Relevant clinical, histologic, and molecular features of these tumors are described in Table\u00a0Clinical features, integrated diagnoses, and percent positivity are summarized in Table\u00a0PLAGL2 amplification. The remainder of CNS tumor cases were immunonegative (<0.05%). Among ETMR cases, PHOX2B expression was observed in varying proportions of neoplastic cells ranging from 0.03% to 1.98% but reaching focally up to 37.19% in \u2018hot spot\u2019 areas  with neural crest\u2010derived tumors (neuroblastoma) and neural crest migration defects (Hirschsprung disease).In normal development, the PHOX2B expression, and in mouse models, a downregulation of PHOX2B inhibits neoplastic proliferation. High PHOX2B expression in neoplastic cells is associated with poor prognosis.Diffuse expression of PHOX2B is a characteristic feature of peripheral neuroblastoma, and its expression is reduced with more cellular differentiation, a feature that was observed in cases 31 (post\u2010treatment) and 34 (ganglioneuroblastoma).n\u2009=\u200917). Ma et al. found no PHOX2B staining in all 210 CNS tumors they examined which included 10 pineoblastomas and three ETMR cases.To date there has been limited study of PHOX2B staining in CNS tumors. Alexandrescu et al. reported PHOX2B immunoreactivity of less than 1% in 4/4 ETMR and 2/4 ATRT, as well as immunoreactivity in 3/6 pineoblastomas (two with 40%\u201350% immunopositivity).We used the same antibody clone as these two other studies, but our standard clinical dilution of 1:100 is significantly more concentrated than the Ma et al. study (1:1000), and slightly more concentrated than Alexandrescu et al (1:125) which could influence the extent and strength of observed staining. In agreement with the previous findings of both studies, none of the examined CNS tumor cases in our study showed the pattern of widespread nuclear PHOX2B immunoreactivity that would be expected in a peripheral neuroblastoma. However, as shown in our data, peripheral neuroblastomas can show a wide range of immunostaining ranging from negative to diffuseOur study showed in 5/7 ETMR cases with at least rare immunoreactivity for PHOX2B. For the most part, the scattered single immunopositive cells observed in more differentiated areas could easily be overlooked by visual inspection. However, the presence of PHOX2B\u2010positive aggregates, creating \u2018hot spots\u2019 of higher percent positivity, up to 39.01%, has not been previously recognized as a feature of ETMR. The irregular distribution of this PHOX2B positivity in conjunction with sampling bias could potentially lead to misdiagnosis, and warrants caution.The biological basis for PHOX2B immunoexpression in primary brain tumors, and the reason for its association with specific tumor types  is unclear. One possible explanation is a sub\u2010clonal differentiation toward PHOX2B\u2010positive neurons, normally present in the embryonic terminal rhombomeres and the respiratory centers of the brain stem.PLAGL2 amplification). PLAGL2 was recently described as a regulator of MYCN expression in peripheral neuroblastoma, with knockdown of PLAGL2 inducing neurite outgrowth and differentiation in neuroblastoma cells.PLAGL2 messenger RNA expression in neuroblastoma patient tumors also correlated to poor overall survival. PLAGL2 is hypothesized to maintain neuroblastoma tumor cells in an undifferentiated state. Determination of whether there is any connection between PLAGL2 amplification in this CNS embryonal tumor and expression of PHOX2B will require closer study.In our study, PHOX2B positivity was also noted in a single unusual case of CNS embryonal tumor NEC (a HGNET with PLAGL2 amplification). While focal positivity for PHOX2B has been previously reported in pineoblastoma, this finding was not observed in our cohort. The pattern of widespread PHOX2B immunoreactivity typical of peripheral neuroblastoma was not observed in any of the pediatric CNS tumors with embryonal features in our study. The underlying mechanism or genetic correlate for focal PHOX2B expression observed in the five positive ETMR cases and in the PLAGL2\u2010amplified case is not entirely clear but may correspond to neuronal differentiation among tumor cells. Care should be taken in the interpretation of focal PHOX2B positivity in any differential diagnosis including CNS embryonal tumors, especially in a small volume sample. Diffuse nuclear staining with PHOX2B in a small round blue cell tumor from the CNS is consistent with metastatic peripheral neuroblastoma. Focal or patchy nuclear staining with PHOX2B is not specific and can be observed in primary CNS tumors, particularly ETMR.PHOX2B expression focally exceeding 20%\u201330% of cells can be observed in ETMR, and focal PHOX2B expression in a subset of tumor cells was observed in a single case of CNS embryonal tumor NEC  immunopositive neoplastic cells are irregularly distributed in some central nervous system (CNS) tumors. A: The patchy distribution of PHOX2B immunopositive neoplastic cells highlights the importance of sampling. The left lower tissue fragment shows only scattered immunopositive cells, while the right upper fragment shows foci with frequent immunopositive cells. B\u2010C: Higher magnification of the latter area shows immunopositive cells are predominantly in the areas with neuropil background compared to the dense undifferentiated areas . D: Rare PHOX2B immunopositive cells in area containing multilayered rosettes. . .Click here for additional data file."}
+{"text": "The correct treatment of most non-transmissible diseases requires, in addition to adequate medication, adherence to physical activity and diet guidelines, as well as health data monitoring and patient motivation. The restrictions caused by the COVID-19 pandemic made telemedicine tools and mobile apps the best choice for monitoring patient compliance. The objective of this study was to analyze the benefits of an m-Health solution designed specifically for chronic patients during the COVID-19 pandemic. A pragmatic clinical trial with pre\u2013post measurements of a single group was carried out with 70 patients (aged 40+) with one or more chronic conditions. Patients were provided with an ad hoc mobile app and health data measuring devices according to their diseases. The health status of the patients was monitored remotely by health professionals who could also modify the patient\u2019s objectives according to their evolution. The results obtained show an average fulfillment of objectives of 77%. Higher fulfillment values: medication adherence (98%) and oxygen saturation (82%); lower fulfillment values: weight (48%), glucose (57%), and distance walked (57%). Globally, the ad hoc app was rated 8.72 points out of 10 (standard deviation 1.10). Concerning the pre\u2013post analysis, there were significant improvements vs. prior apps used by the participants in the following items: improved physical activation and better control of blood pressure, diet, weight, glucose, and oxygen saturation. In conclusion, the telemedicine tool developed was useful in increasing patient engagement and adherence to treatment. Chronic diseases cause an important limitation to the quality of life, productivity, and functional status of patients. They represent a heavy burden in terms of morbidity and mortality and a challenge to the organizational capacity and sustainability of health systems.Chronic diseases are associated with high levels of therapeutic non-compliance. Some factors include the complexity of the therapeutic regimen and intrinsic patient factors, such as negative beliefs towards some drugs or greater fragility. Moreover, medication errors at home are surprisingly frequent. A study by Meyer-Massetti et al. , where dThe patient\u2019s commitment to self-care has been shown to contribute both to therapeutic compliance and the correct use of medications. Self-care is an essential factor that integrates the knowledge, ability, and desire of patients to commit to achieving better results . It invoCommitment to self-care, together with the availability of health resources on the internet, led to the creation of the term e-patient, or people who seek online guidance for their own illnesses or those of their friends and family . NowadayDifferent studies have analyzed the impact of e-patients\u2019 attitudes on healthcare quality, including a study by Kim and Kwon  that conConcerning patient commitment and telemedicine, the VALCRONIC program  proposedHowever, while most patients are satisfied with telemedicine, its acceptability and effectiveness are a source of skepticism among professionals . Most stApart from comparing the clinical results of telemedicine vs. in-person care, there are other issues that require further research, such as how to achieve patient engagement in a digital environment. A study carried out by Barello et al.  concludeChronic conditions suffered particularly during the COVID-19 pandemic, where the attention was focused on COVID-19 patients, overwhelming primary care and making it almost impossible for patients of all other illnesses (including chronic conditions) to access health services. Although this problem was more severe during the first waves, the access barrier created persisted through all pandemic waves . TelemedIn this context, chronic conditions require novel strategies to reduce the frequency of in-person hospital or primary care visits, including tools for: (1) improving therapeutic adherence, (2) avoiding medication errors, (3) increasing engagement in self-care, and (4) remote monitoring.We analyzed the benefits of a complete m-Health solution designed specifically for a diverse group of chronic patients suffering from diabetes, hypertension, hypercholesterolemia, heart disease, or COPD. This m-Health solution responds to the needs of the COVID-19 pandemic, as the tools developed were particularly useful for reducing in-person hospital or primary care visits. Different from other studies, the intervention was carried out in actual clinical practice and not in controlled experimental conditions.The intervention was designed for primary care (family practice), which is a key element in the patient's journey through the Spanish health system. Basically, when patients need medical assistance, they must first visit their primary care physician, who will give them advice or treatment and, if necessary, will send them to other professionals. Primary care physicians are the gatekeepers responsible for authorizing access to specialty care, hospital care, and diagnostic tests . Each patient is assigned a primary care professional so that further visits will always be scheduled with the same professional for better follow-up of each patient. The intervention was designed for primary care as an extra tool for the patient\u2013professional relationship.The use of telemedicine applications in the Spanish health system is still limited but keeps growing. The study presented in  reflectsA pragmatic clinical trial  was carried out, with pre\u2013post measurements of a single group.The study protocol was approved by the Research Ethics Committee of the Sant Joan University Hospital in Alicante . The study was registered with ClinicalTrials, reference NCT04159558.The study was carried out in primary care in seven health centers of the Valencian Community. This care level is ideal for implementing actions that increase patient activation and promote healthy habits, patient compliance, and safety.Subjects: patients over 40 years old who agreed to participate in the study after informed consent and with one or more chronic conditions, such as diabetes, hypertension, hypercholesterolemia, heart disease, or COPD. Patients with neurological or mental illness were excluded.Based on the previous studies ALICE  and VALCFor recruitment, a simple random sampling was applied for all the patients who attended the health centers between December 2020 and June 2021. The physician responsible for patient care was given instructions to register the patients in the experiment after informed consent. Recruitment of 4\u20135 patients per week was estimated, which implied a recruitment duration of 30 weeks.Activity: minimum number of steps or distance walked per day.Weight range .Blood pressure (SBP and DBP).Diet.Oxygen saturation.Blood glucose level.On one side, the intervention was based on the PROPRESE program (PROgram for Cardiovascular SEcondary PREvention)  designedOn the other side, the intervention was also based on the previous ALICE project  designedTeleHealth), which was supplied to patients, as well as peripherals, according to their needs. Doctors were able to remotely access all information needed to monitor the achievement of their patient\u2019s goals.All the previously mentioned functionalities (among others) were included in an ad hoc health app . Patients lacking the necessary devices had the devices provided to them.The patient app has multiple functionalities. It (1) allows patients to input health data  and shows the evolution of these data  along with the patient objectives; (2) rewards patients fulfilling their objectives and show personalized encouragement messages, depending on their evolution and fulfillment of objectives; (3) helps patients with their medicines, showing previously recorded basic information ; and (4) a homogeneous alarm system to remind the patients to take their medicines, start exercising, or take their health measurements.Each patient had a health professional in charge of monitoring her/his health status, keeping track of health alerts, and adjusting her/his objectives. Professionals were obviously required to log in with their personalized access data and were able to visualize the evolution of all their patients in terms of (1) activity  and diet; (2) health data ; and (3) medication adherence. All these data were monitored along with the personalized objectives for each patient. Moreover, the professionals received warning messages whenever some of the data registered for a patient were out of the safety margins. Depending on the evolution of each patient, the professional could modify her/his personalized objectives remotely.The complete architecture of the system is shown in Some screenshots of the patients\u2019 mobile app and professionals\u2019 control panel are shown in (1)A patient form data, including current diseases.(2)A complete list of the patient\u2019s health data values , with clear indications of which objectives are being fulfilled and clear warning signs for dangerous values.(3)If the doctor decides to obtain more details about the evolution of certain data, a complete plot is available, showing values and allowed ranges according to the agreed-upon goals A detailed day-by-day list of certain health data also showing a set of security questions that are answered by the patient when her/his values are potentially dangerous. Again, a clear indication of dangerous symptoms is shown.Demographic data for all participants .A pre\u2013post questionnaire to check the improvements obtained after the intervention period. A Wilcoxon signed-rank test was used to detect significant changes.A daily report of health data vs. goal values , as well as a daily report of treatment adherence. A further stepwise linear regression between the fulfillment of objectives and demographic data was carried out to detect significant effects.TeleHealth app. Gender effects were checked using exact Fisher tests (for yes/no questions) and Chi-squared tests (for rating questions).A final satisfaction questionnaire to rate the TeleHealth app for avoiding medication errors.A specific questionnaire to check the usefulness of the The intervention was designed as a pre\u2013post experiment, with no control group. The data gathered during the experiment include:All statistical analyses were carried out using SPSS software version 28.0.0.0 (190).Data were obtained from 70 patients . The average age was 60.9 years . A total of 8 of 70 (11.4%) lived alone, but 66 of 70 (94.3%) were responsible for managing their medication. A total of 17 of 70 patients (24.3%) took more than 5 types of drugs per day. Although in most cases, their knowledge of ICTs was limited, 63 of 70 (90%) had been using a mobile phone for over 10 years, and 25 of 70 (35.7%) had used a health app previously. The characteristics of those who participated are summarized in Patients agreed with their doctors on their health goals. Thus, the health items to control and the acceptable value ranges were specific for each patient.Globally, there was an average fulfillment of objectives of 77%. The higher fulfillment values were found in medication adherence (98%) and oxygen saturation (82%), while lower fulfillment values were found in weight (48%), distance walked (57%), and glucose (57%) see .All health objectives were analyzed to find possible relations between the percentage of fulfillment and demographic data using stepwise linear regression. The \u201csteps walked\u201d data were dependent on age (older age was associated with lower fulfillment) and the number of weeks using the app (longer usage was associated with higher fulfillment). The detailed results are shown in One of the goals of the intervention was to avoid medication errors. A questionnaire was used to check the patients\u2019 perceived usefulness of the app in these aspects.n = 8), the first question was, \u201cWas the app more useful than the pillbox you used previously?\u201d, and all answers (100%) found the app more useful.For patients that previously used pillboxes (n = 70), 63 patients (90%) answered positively to the following set of questions:The app helped me to avoid medication mix-ups.The app helped me to organize doses according to my doctor\u2019s indications.The app helped me not take incompatible medicines simultaneously.The app helped me to take the dose recommended by my doctor at the correct time.Of all patients , as female patients gave higher marks (average of 8.94) than male patients (average of 8.50). Globally, the app was rated with an average mark of 8.72 out of 10 . A gender effect was found ; health data line charts (88.2%); and the feeling of safety due to the continuous monitoring of doctors through the app (66.2%); while the less-valued aspects were the capability to report app errors (8.8%); the alarms (8.8%); and the help section, including video-tutorials (17.6%).TeleHealth app to their friends or family, and among those who used health apps previously, 56.5% would consider using TeleHealth instead of their previous apps.There were two extra questions related to the global experience of the app. In this sense, 97.1% of participants would recommend the Possible gender effects were analyzed through exact Fisher tests for all the questions, but no effects were found. The complete data are shown in Telemedicine makes it possible to reduce the need for face-to-face consultation, but it does not completely replace it. One of the main objectives is to achieve adequate therapeutic compliance, for which there have already been previous developments since as early as the work of Haynes  or, moreTeleHealth mobile application has proven to be useful in reducing the number of consultations and maintaining adequate control of patients. In this sense, 66.2% of patients felt safer knowing that their doctors could monitor their health through the app . No other gender effects were found, neither for the fulfillment of health objectives nor for the level of satisfaction with specific aspects of the ented in  reflectsTeleHealth app presented in this paper is in line with this tendency: reducing in-person hospital or primary care visits, even during normality periods.The COVID-19 pandemic has accelerated the implementation of telemedicine applications to reduce in-person visits, particularly during its worst episodes ,23. The The fast development of novel telemedicine applications requires a similarly fast evolution of legislation on the topic. Even though there are differences between countries, legislation on telemedicine is lacking or missing in multiple aspects . Among tThere is also a requirement for the elimination of certain barriers that limit the widespread implementation of telemedicine applications. The review presented in  analysesConcerning the different chronic diseases, not all of them benefit from telemedicine at the same level. As an example, the review presented in  analysesPatient and provider satisfaction with telemedicine is extremely relevant. The review presented in the work of Nanda and Sharma  25 prev.Concerning the fulfillment of health objectives and considering that the experiment was carried out in a real environment, the results obtained must be considered relevant to determine whether similar interventions should be generalized. As mentioned in the Results section, there was an average fulfillment of 77%, and the only fulfillment below 50% was that of the weight control (48%). However, weight varies slowly, and this relatively low value may have improved in a longer-duration intervention. Globally, the intervention should be considered successful in terms of the improvement in health objectives.Among the limitations of the study, there are some elements to consider:First, the experiment was carried out in a real context of primary care (family practice). Although primary care is a key element in the patient journey through the Spanish health system, some of the results may not be comparable to those obtained in other contexts .Second, the limited number of participants and the absence of a control group does not allow us to extrapolate the results obtained. Further experiments with a larger and more representative number of participants, including a control group, are required to confirm these results.Third, this study was focused on measuring self-perceived improvements and not the quality of life or organ function improvements. That would require a completely different intervention over a longer period.Fourth, a comparative cost analysis should also be performed to assess the feasibility of telemedicine programs compared to in-person health services. Future studies need to address this feasibility study.Patient engagement, which was a key element of chronic conditions during the COVID-19 pandemic, can be improved with specifically designed telemedicine applications, such as that developed for the current study. Improvements were found in the self-perceived control of physical activity, weight, diet, blood pressure, glucose level, and oxygen saturation when using this tool.Patient\u2013doctor agreement on health data goals allows patients to achieve high fulfillment values, particularly in adherence to medication, as well as oxygen saturation and blood pressure measures.TeleHealth program. Only global satisfaction with the app was higher among female patients. These results should be studied further as they are not in line with previous research.According to our study, there are no significant gender effects in the fulfillment of health objectives or the level of satisfaction with specific aspects of the TeleHealth app was registered through Fisabio  with reference code FS_FOR048, and register number E_102_2020 06.10.2020.The"}
+{"text": "Sexually transmitted infections (STIs) such as chlamydia, gonorrhoea, trichomoniasis, and syphilis, are associated with adverse birth outcomes. Treatment should be accompanied by partner services to prevent re-infection and break cycles of transmission. Partner services include the processes of partner notification (PN) as well as arranging for their attendance for testing and/or treatment. However, due to a complex mix of cultural, socio-economic, and health access factors, uptake of partner services is often very low, in many settings globally. Alternative strategies to facilitate partner services are therefore needed.The aim of this study is to assess the impact of a small financial incentive on uptake of partner services for STIs as part of antenatal care (ANC) services in Zimbabwe.This trial will be embedded within a prospective interventional study in Harare, aiming to evaluate integration of point-of-care diagnostics for STIs into ANC settings. One thousand pregnant women will be screened for chlamydia, gonorrhoea, trichomoniasis, and syphilis. All individuals with STIs will be offered treatment, risk reduction counselling, and client PN. Each clinic day will be randomised 1:1 to be an incentive or non-incentive day. On incentive days, participants diagnosed with a curable STI will be offered a PN slip, that when returned will entitle their partners to $3 (USD) in compensation. On non-incentive days, regular PN slips with no incentive are provided.The primary outcome measure is the proportion of individuals with at least one partner who returns for partner services based on administrative records. Secondary outcomes will include the number of days between index case diagnosis and the partner attending for partner services, uptake of PN slips by pregnant women, adverse birth outcomes in index cases, partners who receive treatment, and intervention cost.th February 2022).Pan African Clinical Trials Registry: PACTR202302702036850 (Approval date 18 Unfortunately, globally rates of STIs remain high. This is particularly true in Southern Africa where control of STIs is hampered by a limited availability of diagnostics, alongside other healthcare access and socio-cultural barriers.Curable sexually transmitted infections (STIs) such as chlamydia, gonorrhoea, trichomoniasis, and syphilis, are associated with adverse outcomes in pregnancy. However, the uptake of PN varies widely, and has not been widely implemented. When testing for chlamydia and gonorrhoea among young people in community settings in Harare, Zimbabwe, we found that only 8.8% (22/248) of partners returned to sites to receive treatment. This was using client referral, whereby the individual diagnosed with an STI is counselled and advised to inform their partners to return, often with the aid of a physical PN slip. This is the standard of care in Zimbabwe and many other settings. However, other strategies such as provider referral and expedited partner treatment have been used in different settings.Partner services are a crucial component of comprehensive case management for an STI in order to prevent re-infection of the index patient. This encompasses both partner notification (PN), whereby a sexual partner of an individual with an STI (the index case) is informed that they may be at risk of an STI, as well as ensuring their attendance for testing and/or treatment. A systematic review of partner services in sub-Saharan Africa found that the proportion of notified partners who sought evaluation or treatment following client referral was 25% (range 0\u201377%) compared to 69% for provider referral and 84% for expedited partner treatment. Importantly, the figures for provider referral and expedited partner treatment in this review, were each based on a single study, demonstrating the limited data available to support these strategies.Provider referral refers to a strategy whereby it is the healthcare professional who informs the partner, which may be particularly helpful where the partner in question is a casual partner, whom the index patient may be reluctant to inform. Expedited partner treatment means that medication or a prescription is given directly to the index patient to be given to their partner. This may save time for both the healthcare provider and partner, but may face legal barriers unless specific laws authorising its use are in place. This demonstrates that one must consider the broader set of facilitators and barriers to PN that will be unique to each individual. For example, risk of intimate partner violence must be particularly considered in pregnancy, with two-thirds of pregnant women in one study in Harare reporting a history of physical, sexual and/or emotional violence during pregnancy.Patients\u2019 individual assessment of the risks and benefits of each PN method will vary with context. In antenatal care, one may assume that rates of PN would be better, potentially due to higher proportions of individuals in stable relationships, and the added consideration of ensuring the health of the baby, which may increase indexes\u2019 motivation to inform their partner, and partners\u2019 motivation to attend for treatment. However, several studies in pregnant women reveal a wide range of rates of completion of PN. In particular, they had genuine concerns regarding their physical safety, with reports of violence noted. Furthermore, there are also social and emotional risks involved. In addition to potentially precipitating relationship breakdown, accusations of pre- or extra-marital relations may also be disseminated to family, friends or other community members, which may have an impact on an individual\u2019s reputation. Appropriation of blame and spreading rumours were also raised by patients seeking care in Botswana. Overall, there was felt to be a \u201cdisconnect between the request to notify partners and the reality\u201d of doing so, with the above challenges not being fully acknowledged. There are also important systems-level barriers to individuals seeking out any STI care, including availability and accessibility of services, with cost being a frequently mentioned barrier to access. These are all important factors when considering strategies to improve PN uptake. Although higher numbers of partners receiving treatment is optimal from an STI control perspective, individuals must not be exposed to unacceptably high levels of risk in order to achieve this.Our experience with young people in Zimbabwe revealed that they found it very difficult to inform partners, and felt ill-equipped to have such conversations with their partners. Chokoet al. (2021) investigated the use of partner-delivered HIV self-test kits, with and without financial incentives, in antenatal care in Malawi. Secondary distribution of test kits substantially increased HIV testing by male partners of pregnant women, by similar magnitudes with and without an incentive. Another study by Chokoet al. (2018) found that higher proportions of male partners of pregnant women were tested for HIV and linked into care or prevention, when the pregnant woman was provided with two HIV self-test kits for their partners and either a $3 incentive, $10 incentive, or phone reminder. However, no significant increase was noted when HIV self-test kits were provided alone.This is particularly important for financial incentives, which have the potential to cause both benefit and harm. Incentives have been used in other settings to promote uptake and adherence to various health interventions. This includes improving uptake of HIV testing and result receipt, linkage to HIV treatment and voluntary medical male circumcision, and reducing high-risk sexual behaviour. Another trial in rural Zimbabwe also demonstrated that small non-monetary incentives were associated with higher levels of couples\u2019 HIV testing and counselling, and HIV case diagnosis.A randomised controlled trial in Harare, Zimbabwe of both fixed and lottery-based incentives given to caregivers showed significantly increased HIV testing uptake among older children and adolescents. Another study in Malawi used a social contact recruitment programme to recruit social contacts (rather than partners) of individuals with STI syndromes (both with and without HIV), and community controls. Participants (\u201cseeds\u201d) were given coupons to give to their social contacts to come to the clinic for a health promotion visit, including HIV testing and counselling and STI syndromic screening, with seeds receiving $2 for each social contact successfully referred to the clinic. This study demonstrated that this was a feasible, effective and efficient method to identify individuals with undiagnosed HIV. There are fewer examples related to incentives for PN for STIs and a particular paucity of evidence from randomised controlled trials. In a qualitative study in Malawi, healthcare workers at an STI clinic felt that incentivising both partners and couples who attend together would have the greatest effect on improving treatment of partnersOverall, incentives to improve uptake of PN for STIs have received insufficient attention to establish a clear evidence base regarding their use.Partner notification has very low take-up in many settings globally. Alternative strategies to facilitate both index patients informing their partners, and particularly partners attending for treatment, must be considered to reduce reinfection, particularly for pregnant women. Incentives, financial or non-financial, to facilitate PN should be considered as a possible strategy. This approach has been used to promote uptake of other health interventions and could be programmed within services especially as it focuses on achieving a discrete outcome rather than requiring repeated engagement over time.The rationale behind this intervention is that providing a financial incentive may specifically ameliorate some of the socioeconomic barriers that partners face in attending clinic for treatment, in particular transport costs. Importantly, it is not expected that this intervention will significantly influence the major barriers present for index cases to notify their partners in the first instance.The aim of this study is to assess the impact of a small financial incentive on uptake of partner services for sexually transmitted infections within antenatal care services in Zimbabwe. It will also inform future studies related to partner services, in terms of feasibility and operationalisation of incentives.. Such PHCs provide routine nurse-led antenatal care.A cluster randomised trial will be embedded within the \u201cIPSAZ study\u201d , a prospective interventional study being conducted in urban primary healthcare clinics (PHCs) in Harare province, Zimbabwe, aiming to evaluate a strategy for integration of point-of-care diagnostics for STIs into ANC settingsPregnant women will be consecutively enrolled into the IPSAZ study when attending a study clinic for routine ANC. The only exclusion criteria are prior enrolment into the IPSAZ study, or being unable or unwilling to provide written informed consent.. In summary, in addition to HIV and syphilis testing provided as part of routine care, the IPSAZ study will provide on-site opt-out testing for chlamydia and gonorrhoea using Xpert\u00ae CT/NG assay (Cepheid), for trichomoniasis using OSOM\u00ae Trichomonas Rapid Test (Sekisui Diagnostics), and for Hepatitis B using the HBsAg 2 . Comprehensive case management, including treatment and partner notification, will be provided as per national guidelines, ideally on the same day as sample collection. For participants unable to be treated on the same day, they will be contacted by telephone up to five times over 28 days, to advise them to return for treatment. For participants with symptoms, participants will be given the option to receive immediate syndromic treatment, or to receive tailored treatment following processing of their results.The procedures for the main IPSAZ study are described in detail in the main study protocolAll pregnant women will be contacted by telephone after birth, to collect data on birth outcomes. Alongside this, they will be asked if they notified their partners, if their partners were treated, and if there were any negative consequences of this, including verbal, physical, sexual, or other abuse, relationship breakdown, negative reactions from friends or other family members, or any other ramifications.As per standard of care, partners will be notified by client referral. Post-test counselling to participants diagnosed with an STI or treated for a syndrome will include the importance of partner treatment. They will be provided with PN slips for their partners to return for presumptive treatment. Index cases can receive as many PN slips as they require. Partners who attend the study clinic and present their PN slip will be provided with presumptive treatment free-of-charge. Partners will be considered lost-to-follow up if they have not returned within 28 days after treatment of the index case.The intervention will be provision of $3 (USD) provided to a partner on returning to the clinic for treatment. The amount was based on in-depth interviews with pregnant women, male partners, and midwives, recruited when attending or working at one of the intervention clinics, as well as discussions with members of the intervention team. Questions on appropriate incentive value were embedded within broader discussions about PN, including different methods of PN, associated challenges, and feasibility of PN. Specifically for incentives, stakeholders were asked what they thought about the idea, any potential negative consequences, and what a suitable value would be for an incentive. Male partners often noted that an incentive should cover cost of travel, but also leave the partner with some additional money to spend. In contrast, pregnant woman and midwives tended to say any financial incentive, even very small, would prompt partners to attend. They also noted that unintended consequences could include using the incentive for alcohol or drugs, or for individuals who were not the index\u2019s real partner to attend. A compromise value of $3 was therefore chosen, with a key factor being that $3 covers a return journey by public transport from the majority of locations from where pregnant women  are likely to travel.Randomisation of each clinic day will be performed in a 1:1 ratio between days where issued slips are associated with an incentive and days where no incentive is issued. Randomisation by clinic day was chosen as a method to allocate incentives, in preference to individual randomisation, to prevent contamination. Additionally, if some individuals presenting on the same day were offered an incentive and others were not, this may lead to a greater perception of unfairness amongst participants.Randomisation will be performed by a statistician not involved in the IPSAZ study, using the formula \u201c=INT(RAND*2)\u201d in Microsoft Excel for each clinic day. Randomisation outcomes will be recorded on a document produced for each month, and kept at each clinic site. The intervention team will refer to this document to determine whether it is an \u2018incentive\u2019 or \u2018non-incentive\u2019 day. For each individual pregnant woman, it will also be documented whether an issued PN slip was associated with an incentive or not. Similarly, when partners return it will be recorded if an incentive was provided. To ensure compliance with the randomisation log, this data will regularly be cross-checked to ensure that clients are being provided the correct slip based on day of attendance.It is not possible to blind participants or researchers to the intervention. However, participants will only be informed of the availability of an incentive once they test positive on an incentive day and have already informed the clinical team how many PN slips are required. This is to prevent participants from providing an artificially elevated number of partners in order for incentives to be provided to individuals who are not actual partners of the index case. Of note, women could still return with a male who is not a sexual partner, and this would be difficult to detect. However, given the factors discussed regarding ensuring the health of the baby, and that this would still require disclosure of treatment to another male, we feel that the risk of this is low.The primary outcome measure is the proportion of indexes with at least one partner who returns to the study site for partner services within 28 days of index diagnosis. Each PN slip will also have a unique ID that links partners to the index client, thus allowing for recording of this data. The main secondary outcome will be the number of days between index case diagnosis and the partner attending for partner services. Additional secondary outcomes will include uptake of PN slips by pregnant women, adverse birth outcomes in index cases, number of partners who receive treatment, and intervention cost. Number of partners who receive treatment will be recorded from our study antibiotic administration records, and compared with that reported by participants during telephone follow-up.Furthermore, the proportion of indexes with at least one partner who returns to the study site for partner services any number of days from index diagnosis, will also be measured as a secondary outcome..As a trial embedded within a larger study, sample size calculations were not performed to power this trial. The main IPSAZ study has a target sample size of 1000 pregnant women, based on an estimated composite STI prevalence of 30%, a desired precision of 3%, an alpha of 0.05, and an additional 10% of participants to account for invalid test resultsFrom the initial pilot data from the IPSAZ study, we estimated a 30% prevalence of curable STIs and a recruitment rate of 5 participants per clinic day. For analysis, each clinic day will be considered as a unit of randomisation. It is therefore predicted that 300 index participants will receive partner notification slips, over 200 recruiting clinic days. This equates to 100 \u2018clusters\u2019 per arm, with an average of 1.5 participants per cluster.The intra-cluster correlation coefficient (ICC) is assumed to be zero as the outcome is not expected to be more or less likely in participants having attended on the same day, compared to on different days. However, given the very small size of the clusters, even if the ICC was higher, it is unlikely to have a meaningful effect on the design effect size.Initial data suggest that an estimated 30% of indexes have at least one partner returning for treatment. Assuming this, and an alpha of 0.05, a power of 0.8, an ICC of zero, 100 clusters per arm, and 1.5 participants per cluster, results in a minimum detectable odds ratio of 1.96 for the intervention . A higheSimple point estimates for each arm will be presented by calculating the number of participants given a PN slip for whom at least one partner returned to the study clinic for treatment divided by the total number of participants given a PN slip. This was chosen over a mean of cluster responses, due to the higher importance of giving equal weight to each individual, over that of each cluster. Analysis will be by intention-to-treat. Analysis per protocol will also be conducted as a sensitivity analysis, based on the type of PN slip that was recorded as being given..Trial arms will be compared using individual-level logistic regression, using robust standard errors to account for any clustering. Robust standard errors will be used, over generalised estimating equations or random effects models, as the expected correlation within clusters is minimal. Results will be presented as per the CONSORT extension for cluster trials. This process evaluation follows the MRC process evaluation framework, with research domains including fidelity, coverage, responses to and interactions with the intervention, interactions and consequences, and context. Key aspects relevant for PN and this trial are feasibility, acceptability to both pregnant women and partners, how incentives influence interactions between the index case and their partners, and unanticipated pathways or consequences. Of note, assessments of acceptability will explore comparisons between standard PN, incentivised PN, and also no PN, which may be the most acceptable option for some participants. Methods include; in-depth interviews and focus group discussions with pregnant women, healthcare workers, members of the intervention team, and male partners; unstructured observations; and routine monitoring data. Unstructured observations will be of clinical encounters and will be conducted by a research assistant not involved with delivery of the intervention. As observation may impact consultations, permission will be requested from participants, confidentiality will be re-assured, and the research assistant will aim to be as unobtrusive as possible. Interviews with pregnant women and partners will be conducted after PN has been attempted or completed, in order to assess for unintentional consequences or adverse outcomes. As previously mentioned, negative consequences of PN will be documented during a post-natal telephone call.An accompanying mixed methods process evaluation will be conducted to further understand the PN process and the influence of incentives on uptake, within the broader IPSAZ study process evaluation, described in the main study protocol.Data management procedures for this incentives trial are the same as for the main IPSAZ study, and are described elsewhereEthical approval for the IPSAZ study protocol, including the incentives trial, has been provided by the Medical Research Council of Zimbabwe (MRCZ/A/2899), the London School of Hygiene & Tropical Medicine Research Ethics Committee (26787), and the Biomedical Research and Training Institute Institutional Review Board (AP176/2022).Written informed consent to participate in the main IPSAZ study will be obtained in either English or Shona, depending on participant preference. This will include from pregnant minors, who are considered emancipated in Zimbabwe.Importantly, although participants will be counselled on the benefits of PN, it is recognised that participants may have valid concerns about disclosing this information to partners, in terms of risk of relationship breakdown or intimate partner violence. As a result, we will support participants in coming to their own decision on whether to inform their partner or not.Adverse events will be documented and discussed at regular debrief sessions. This will include any instances of harm to either indexes or their partners, as a result of the partner notification process. This includes some of the potential negative consequences that we will routinely collect from participants during follow-up, including verbal, physical, sexual, or other abuse. For participants reporting abuse, the needs of the participant will be discussed as part of a multi-disciplinary team at the clinic. Referral processes will be integrated into existing clinic processes as much as possible. Possible onward referrals include to governmental sexual and gender-based violence clinics, charitable organisations focussed on intimate partner violence, counselling services, and/or the police, if required. Additionally, if the participant is under the age of 18 years, referral to social services will be considered. Adverse events may also be reported to the Medical Research Council of Zimbabwe if warranted, for example due to severity.Results will be submitted to open-access peer-reviewed journals, presented at academic meetings and shared with participating communities and with national and international policy-making bodies.There has been a significant push towards development and integration of new diagnostics for STIs into health systems in the Global South. Importantly however, without concurrent improvements in the key tenets of STI management, namely risk reduction counselling, condom use, and effective partner notification and treatment, the potential benefits of aetiological diagnosis may be limited. One strategy that may help to support partner services is the use of incentives, which may be financial or non-financial. In both instances, the aim is to nudge the partner so that they are more likely to attend a clinic for treatment. However, particularly for financial incentives, they may also improve the likelihood of an index patient informing a partner, if it makes them feel more able to deliver \u2018bad news\u2019 if accompanied by something beneficial.. Importantly, as the direct beneficiaries of the incentive are the partners, we anticipate this is less likely compared to if the incentive was directly benefitting the index. Additionally, it will be emphasised to the intervention team that pregnant women should be supported in coming to the right decision for them, which may be not notifying their partner if there is a risk of negative repercussions.We have chosen $3 (USD) based on input from key stakeholders, from an initial potential range of $1 to $10. An important factor in choosing $3 was that we hoped this would facilitate partners to attend, but not induce them. From an ethical perspective, there is a risk of coercion with larger incentives in socioeconomically deprived communities. Given that PN may carry a risk of violence or relationship breakdown, it is important that the incentive does not force women to inform their partners due to the size of the incentive, against their better judgementA further consideration is that higher incentives, although likely to be more effective in research settings, are less likely to be implemented in practice in resource-limited health settings. A one-off payment of $3 could be a programmable intervention, and also be more equated to a \u2018nudge\u2019 compared to $5 or $10 which are more akin to direct payments. If found to be successful, other mechanisms to enhance sustainability will need to be considered. For example, they could be used as an entry point for HIV testing for this high-risk group, or other interventions.. Client referral will be used in this study, largely due to what is likely to be feasibly implemented in routine practice in the future. In Zimbabwe, chronic staff shortages make more resource-intensive PN strategies much less likely to be implemented.Another important decision was the PN strategy to be used. There is currently no consensus on the most appropriate PN strategy, and ideally this should be tailored to the particular setting. The difficulty of explaining that someone might have an infection without symptoms was raised. Furthermore, general trust in health systems and health providers will also inform these decisions. Incentives and other methods to promote PN will therefore be important in facilitating this shift.Importantly, although a shift to aetiological testing will bring a host of advantages to STI management in Southern Africa, it will also bring some additional challenges. Given that syndromic management has been in place for decades, a cultural shift will be required for both clients and healthcare workers, towards an understanding of asymptomatic infections, and the need for screening and treatment. This may have ramifications for PN, with the potential for reluctance if neither index patient not partner have symptoms. This was raised in a mixed methods study in Gaborone, Botswana, where a lack of symptoms was noted as a barrier for index cases to inform their partners, as they did not think their partner had an infectionA key strength of this study is that the intervention has been tailored and informed based on input from key stakeholders. Additionally, although sample size calculations were not performed with this trial in mind, it will likely be moderately powered to detect clinically significant differences in PN uptake.Important limitations relate to generalisability. Firstly, this study will be conducted in urban PHCs in Harare. Results are likely less generalisable to rural settings, where distance to nearest clinic, availability of transport, expected quality of care, and socioeconomic differences, may alter the perception of such an incentive. Secondly, this is an ANC study, which is unique for several reasons; 1) All indexes will be pregnant women; 2) most if not all partners will be male; 3) the health and wellbeing of the baby will likely be an important factor in decision-making; and 4) there may be a higher proportion of stable relationships compared to other settings. These unique circumstances mean that any attempts at extrapolating these findings to other settings or sub-populations must be done so with a high level of caution.. Furthermore, as data on both number of partners and number of partners treated will be collected, we will be able to make an assessment of the degree to which partner notification was successful in index cases with multiple partners.A further limitation is that our primary outcome is based upon at least one partner returning for treatment. This does not take account of index cases with more than one sexual partner. However, demographic health and survey data from Zimbabwe reported that less than 1% of surveyed women and 2.5% of surveyed men reported concurrent sexual partners in the preceding 12 monthsFinally, all clients and their partners receive treatment free of charge in this study, which is not representative of clinic settings in Zimbabwe, where fees and co-payments are standard. This may therefore influence how we interpret differences between groups, as even in the control arm, an important barrier to access has already been removed. Additionally, as treatment is available from most PHCs, there is a risk that partners may attend the PHC most convenient to them, and thus not be included as a study outcome. However, providing treatment free of charge in the control arm will reduce this risk.As far as we are aware, this is the first randomised controlled trial to assess the effect of a small financial incentive on PN for STIs. It will provide important data on the potential for the use of financial incentives to improve uptake of PN in urban, Southern African settings. Although it will not replace the need for cohesive and funded PN strategies tailored to the population served, incentives may enhance baseline uptake, allowing for reduced rates of re-infection and their associated complications. Thank you to the authors for addressing the reviewers' comments.\u00a0I have reviewed the revised version and have no further\u00a0comments.Is the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Not applicableReviewer Expertise:Implementation science; epidemiology; sexually transmitted infectionsI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. I have reviewed this revised version and I have no further\u00a0comments.Is the study design appropriate for the research question?PartlyIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Not applicableReviewer Expertise:NAI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Financial incentives to improve uptake of partner services for sexually transmitted infections in Zimbabwe antenatal care: protocol for a cluster randomized\u00a0trialReview of the protocol on\u00a0 Thank you for the opportunity to review the protocol which aims to\u00a0assess the effect of a small financial incentive on improving PN for sexually transmitted infections within antenatal care services in Zimbabwe. The proposal is nested in a broad study which is investigating point-of-care diagnostics for sexually transmitted infections and antimicrobial resistance in antenatal care in Zimbabwe. The proposed design is a clustered randomized trial and the clustered are structured according to randomizing the alternative days of incentive given and no incentive given.\u00a0 The study will use the existing healthcare systems guideline on the management of STI where a partner notification slip is used to the patient who is the index case, then the slip gets delivered to the sexual partner for use to access STI treatment. Index cases can receive as many PN slips as they require. Partners who attend the study clinic and present their PN slip will be provided with presumptive treatment free-of-charge. The intervention will be provision of $3 (USD) provided to a partner on returning to the clinic for treatment.\u00a0 The proposal is methodologically sound and covers all gaps required to enable replicability.\u00a0 I have only one concern that can easily be addressed:Partners will be considered lost-to-follow up if they have not returned within 28 days after treatment of the index. The researchers say that\u00a0 The concern is that the reality is that not all sexual partners are able to use the health facility that is used by the index case. I read about possible risks for the study of which one of them is patient following different pathways? I wonder if this will accommodate the loss-to-follow up but I would prefer the researchers to put it clearly in order to strengthen the section of partner lost-to-follow up. Overall the protocol is elaborate and comprehensive and will be useful for replication regarding feasibility and operationalization of incentives.Is the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Not applicableReviewer Expertise:Social epidemiology and interventions for sexual and reproductive health across populations.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Brief explanation about how the randomisation by clinic day will be implemented, specifically how will it be ensured that staff will offer the correct PN strategy for the allocated clinic day as this can have implications for contamination\u00a0Double check the OR outlined in the table 1 and the estimated minimum detectable OR in the text.\u00a0Clarify as part of process evaluation what structured and unstructured observations will be conducted, by whom and its ethical implications if any.Telephone calls will be conducted post birth when participants will be asked about negative impact if any of PN. Besides reporting to MRC, please address clearly what measures will be in place to address negative effects of PN among participants of both the study arms and especially intervention arm.\u00a0The protocol has estimated for the minimum number of sexual partners who will return for treatment. it will also be useful to briefly discuss the nature of sexual partnerships in Zimbabwe  and its potential implications on outcomes especially as there is growing evidence that nature of sexual partnerships has implications on PN outcomes.It will be useful to briefly outline the theory of change informing the proposed intervention and anticipated levers that will facilitate behaviour change. currently this information is scattered throughout the manuscript in separate sections and can benefit from clarifying the anticipated behaviour change pathway.\u00a0 Best wishesThe manuscript is well written and describes the proposed intervention, its rationale and evaluation strategy clearly. The manuscript can benefit from clarifying the following issues:Is the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Not applicableReviewer Expertise:Sexual partnerships, partner notifications, bacterial STI and HIV, development and evaluation of behavioural interventions.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. It is a real pleasure to be able to review this protocol for a CRT in Zimbabwe using a $3 financial incentive to increase partner clinic attendance following an STI diagnosis of an index. The authors have articulated very clearly multiple barriers to clinic attendance in the target population but also more generally. What might be more useful is a justification and a reflection as to why the offer of a $3 financial incentive conditional on clinic attendance might address all the barriers cited. In other words, some thought on the mechanism of how the intervention might produce the intended effect would be more important and would provide rigour to the argument of incentives as an intervention.\u00a0 The choice of the clinic day as a cluster is very interesting and one that has been used successfully to reduce time in another similar study in Malawi. It might be more helpful, though, to pay more attention on the small nature of the cluster, here the authors state number of eligible participants per clinic day of as few as 1 participant. This raises serious problems a) with respect to the use of a cluster randomized trial design whose basis is that there is variation within and between clusters. Such an argument of variation may not apply here if the cluster is largely made of size 1 b) even if a CRT were to apply, there is extremely high likelihood that many such small clusters will produce a zero participant achieving the outcome. This needs a lot of thought at the outset as it implies that standard CRT methods of analysis may not hold. Other more complex i.e. zero inflated models or methods may thus have to be used or considered. I would like to ask the investigators to reconsider the implementation of the study on the basis that it seems already highly underpowered. They state that no study power can be computed because the overall sample size is fixed by the parent study. This is a little puzzling because as CRT with an intervention component it is imperative to compute and demonstrate that the trial will have sufficient power to detect a difference in the primary outcome at least. In the absence of such a calculation I feel that it may be worthwhile conducting this as an exploratory study as opposed to a full scale CRT. The assumption of a zero ICC may need additional thought. While there may be little no variation within clinic days at any one given clinic, this may not be the case between health facilities between clinic days. Choko et al PLOS Med 2019 still assumed k of 0.10 under very similar circumstances in Malawi and their analyses showed that ICC was not equal to zero. This implies that the stated sample size of 100 cluster per arm is smaller than the correct number of clusters per arm i.e. the true required number of clusters per arm will be larger.Is the study design appropriate for the research question?PartlyIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Not applicableReviewer Expertise:HIV testing, linkage to prevention and treatment, cluster randomized trialsI confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. This protocol is for a randomized controlled trial evaluating the impact of a financial incentive on partner notification and partner treatment for curable sexually transmitted infections diagnosed among pregnant women attending antenatal care in urban Zimbabwe. It is nested within a prospective interventional study of etiologic screening and treatment of STIs in pregnancy. Pregnant women diagnosed with a curable STI will be randomized, by day, to either standard partner notification procedures by client referral (with free treatment for the partner) or to a small financial incentive for each partner referred and treated. The primary outcome is the proportion of index patients with at least one partner who presents to the study clinic for treatment within 28 days.General comments: Overall, this is a clearly written protocol. However, several details of the methods can use clarification and the discussion of the complexities of partner notification could be expanded upon as below:The discussion about the potential harms of partner notification for the index patient  in both the introduction and discussion is underdeveloped. There is a growing body of literature on facilitators and barriers to partner notification, including from Southern Africa. It would be helpful to more clearly describe what has been identified as barriers in both the authors\u2019 recent work and elsewhere in the literature and then to describe which of those barriers the financial incentive may help to overcome.A more nuanced discussion of how the barriers/facilitators to partner notification may be different in the antenatal care context  would be helpful \u2013 in the introduction, paragraph 4 the concern about the \u2018health of the baby\u2019 is mentioned; while this seems likely to be true, is there literature or formative work to suggest this will increase motivations for partner notification? Is there data to support the statement that more of these women will be in stable relationships? In some settings, pregnancy can be a higher risk time for intimate partner violence \u2013 is there any data on this from Zimbabwe? What resources will be available to women who report social harms from partner notification?Will study participants in the control arm be asked whether their partners were notified and sought treatment elsewhere? The authors mention that the free partner treatment at the study site(s) may motivate partners to present there for care, but if they have to pay for transport they may choose to go somewhere closer. It seems not asking about treatment sought elsewhere among the control partners could bias the results in favor of the intervention.Why was 28 days chosen as the window for partner treatment in the primary outcome?The secondary outcomes include uptake of PN slips by pregnant women \u2013 will this be compared between the arms? Earlier in the methods it states that participants will only be informed of the availability of an incentive once they test positive on an incentive day and have already informed the clinical team how many PN slips are required \u2013 will they be allowed to request more PN slips after learning of the intervention?https://pubmed.ncbi.nlm.nih.gov/34304619/)In the discussion, the important issue of partner notification in the context of asymptomatic screening (in a setting where syndromic management is standard of care) is raised \u2013 this is an important issue and the discussion could be expanded and also supported with literature Minor comments: Systematic review of partner services in sub-Saharan Africa found\u2026\u201d \u2013 this is missing a referenceIntroduction, paragraph 3 mentions a \u201cIntroduction, paragraph 7 mentions a study in Malawi using a social contact recruitment program and $2 financial incentive \u2013 would be helpful to mention the outcome of this study.In the abstract and the study aim statement in the last paragraph of the introduction, the outcome is stated as \u201cimproving PN\u201d or \u201cimproving uptake of PN\u201d \u2013 however more concretely the goal is to assess the impact of the financial incentive on completion of partner treatment (as opposed to only notifying partners who do not then present for treatment) - recommend being more specific in these statements.Randomization section: consider using more scientific/neutral terminology in place of \u201cgaming the system\u201d which could be perceived as judgmental or dismissive of the potential complex motivations for an individual to do so.Is the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Not applicableReviewer Expertise:Implementation science; epidemiology; sexually transmitted infectionsI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above."}
+{"text": "Epilepsy is a prevalent disease that requires personalized care to control seizures, reduce side effects, and ameliorate the burden of comorbidities. Smoking is a major cause of preventable death and disease. There is evidence that patients with epilepsy smoke at high rates and that smoking may increase seizure frequency. However, there is a lack systematically synthesized evidence on the interactions between epilepsy and seizures and smoking, tobacco use, vaping, and smoking cessation.This scoping review protocol guided by the Joanna Briggs Institute Manual for Evidence Synthesis and the PRISMA Extension for Scoping Reviews will investigate what is known about the interactions between smoking and epilepsy. This review will include the population of persons with all types of epilepsy or seizures and examine an inclusive list of concepts including tobacco use, vaping, nicotine replacement, and smoking cessation. The MEDLINE, Embase, APA Psycinfo, CINAHL, Cochrane, Scopus, and Web of Science databases will be searched. Following systematic screening of records, data will be charted, synthesized, and summarized for presentation and publication.No ethical approval is required for this literature-based study. The results of this scoping review will be submitted for publication in a peer-reviewed journal. This synthesis will be informative to clinicians and direct further research that may improve health outcomes for people with epilepsy.https://doi.org/10.17605/OSF.IO/D3ZK8).This protocol is registered with the Open Science Framework (DOI:  There are an estimated 50 million people living with epilepsy worldwide . People Cigarette smoking is a leading cause of preventable death . In the Nicotine, the primary addictive chemical in tobacco smoke, has been shown to have a proconvulsive effect in animal models. This effect is attributed to the activation of nicotinic acetylcholine receptors (nACHRs) in the brain . Animal Nicotine may however have anticonvulsant effects in certain contexts. Autosomal Dominant Sleep Related Hypermotor Epilepsy  is a rare inherited focal onset epilepsy syndrome associated with mutations in genes that encode the subunits of nACHRs . In vitrBoth the proconvulsant and anticonvulsant effects of nicotine described above have been demonstrated clinically. Seizures have been reported in cases of nicotine poisoning from nicotine patches reported to poison control centers . SeizureThe effect of tobacco smoke on the seizure threshold may be due to the effects of nicotine described above, or because of other chemical compounds. For example, tobacco smoke contains chemicals such as arsenic, ammonia, and acetone that have been shown to induce seizures under certain conditions in animal studies . FurtherClinicians who care for people with epilepsy and seizures have a unique opportunity to positively impact the health of their patients by employing a holistic approach to neurologic care informed by an understanding of the interactions of epilepsy with lifestyle factors including smoking. Choice of epilepsy directed therapy such as antiseizure medication or surgery should be tailored to an individual patient\u2019s comorbidities, risk factors, and preferences. Moreover, smoking cessation pharmacotherapy must be considered carefully in patients with epilepsy as bupropion is contraindicated and varenicline is recommended for cautious use in patients at risk for seizures . CurrentThe objective of this scoping review is to systematically scope the existing research on the interaction of tobacco and related products and epilepsy. This review is directed towards the following questions:What is the prevalence of tobacco use among people with epilepsy?Does tobacco use/smoking affect seizure control in patients with epilepsy?Does tobacco use, smoking, or vaping (e-cigarette use) increase an individual\u2019s risk of developing epilepsy?What is known about vaping and seizures or epilepsy?What is known about smoking cessation in the epilepsy population?Do antiseizure medications interact with nicotine, smoking, or vaping?We will identify the quantity and heterogeneity of studies investigating the above questions, summarize the results of these studies, and identify gaps in knowledge. This study aims to be informative to practicing clinicians caring for patients with epilepsy and researchers designing future studies to elucidate interactions between epilepsy and tobacco use.https://doi.org/10.17605/OSF.IO/D3ZK8)This scoping review protocol is guided by the framework described by the Joanna Briggs Institute (JBI)  and the Research questions were identified through nonsystematic review of literature published on this topic and through discussion between authors. The relevant questions are listed in the study objectives section of this protocol. These questions may be revised, amended, or potentially replaced during an iterative review process.The Population-Concept-Context (PCC) framework is recommended by the Joanna Briggs Institute for scoping reviews and will be used to inform our inclusion criteria  Table 1Table 1. We have elected to include studies that examine the interaction between smoking and epilepsy or seizures in both adult and pediatric samples. While this could decrease the internal validity of our synthesis, for the purpose of this scoping review, we prioritize capture of extant knowledge in this field. Our preliminary search described in Step 1 of We will use a three-step search process to identify records to include in this scoping review as recommended by the Joanna Briggs Institute  Table 2Table 2.An experienced medical librarian (MCF) was consulted on review methodology and search technique. A medical subject heading (MeSH) analysis of known key articles provided by the research team [mesh.med.yale.edu] was done and scoping searches were conducted in each database. An iterative process was used to translate and refine the searches. To maximize sensitivity, the formal search will use controlled vocabulary terms and synonymous free-text words to capture the concepts of \u201ctobacco smoking\u201d and \u201cepilepsy\u201d. We will include search terms to capture studies on specific tobacco products utilized in various geographical settings to be as inclusive as possible. The search strategy was peer reviewed by a second librarian, not otherwise associated with the project, using the PRESS standard . An examwww.endnote.com]. This set will be uploaded to Covidence [www.covidence.org] for screening. Three authors  will independently screen titles and abstracts and subsequently full text records using the prespecified inclusion criteria outlined in Search results will be pooled in EndNote 20 and de-duplicated Reviewers' comments:Reviewer's Responses to Questions <font color=\"black\"> Comments to the Author1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions? </font> The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.Reviewer #1:\u00a0YesReviewer #2:\u00a0Yes********** <font color=\"black\"> 2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses? </font> The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions  to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.Reviewer #1:\u00a0YesReviewer #2:\u00a0Yes********** <font color=\"black\"> 3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable? </font> Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.Reviewer #1:\u00a0YesReviewer #2:\u00a0Yes********** <font color=\"black\"> 4. Have the authors described where all data underlying the findings will be made available when the study is complete?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data\u2014e.g. participant privacy or use of data from a third party\u2014those must be specified. </font> The Reviewer #1:\u00a0YesReviewer #2:\u00a0Yes********** <font color=\"black\"> 5. Is the manuscript presented in an intelligible fashion and written in standard English? </font> PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1:\u00a0YesReviewer #2:\u00a0Yes********** <font color=\"black\"> 6. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.You may also provide optional suggestions and comments to authors that they might find helpful in planning their study. </font> Reviewer #1:\u00a0I do value the importance of smoking in epilepsy pathogenesis and pharmacotherapy and would like the authors to add another question: the impact of passive smoking during pregnancy on thr incidence of epilepsy development in offsprings via retrospective evaluation.Reviewer #2:\u00a0The scoping review protocol was prepared according to the standardized method stipulated by JBIM. The review objectives are all clear and well defined. Just one suggestion, if the keyword for Tobacco should expand: 'Tobacco products' to ensure that the authors won't miss any kind of specific tobacco products that used in other studies from local settings such as kretek, Shisha, Bidis. The rest is all good and clearly written.********** <font color=\"black\"> 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose \u201cno\u201d, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. </font> Yes:\u00a0Mohamed MostafaReviewer #1:\u00a0Reviewer #2:\u00a0No**********https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at\u00a0figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,\u00a0 11 May 20231. The title appears very vague, the objectives and the research question is not reflected in the topic. Consider providing a more specific topicWe thank the editor for this helpful comment. We have rewritten our title to more specifically describe our topic of investigation.We have changed our title to: \"How do smoking, vaping, and nicotine affect people with epilepsy and seizures? A scoping review protocol\"1. The introduction is very non specific, the biochemical and social explanation for studying the effect of smoking, vaping and other tobacco use among patients with seizures needs to be elaborated.We thank the editor for this helpful comment. We agree that our manuscript could benefit from further explanation of our study's rationale.We have added content to the introduction to describe the biochemical rationale for studying the effects of smoking, vaping, and tobacco use among patients with epilepsy or seizures. To the second paragraph of the introduction, we have added two sentences. One stating the relevance of our topic to the health outcomes of people with epilepsy. The other comments on evidence suggesting that people who smoke may be at risk for developing epilepsy. We have added three paragraphs to the introduction section that describe the biochemical basis for the proconvulsive effects of nicotine, a possible role of nicotine as an anticonvulsant, and potential effects of the unique exposure of tobacco smoke on the seizure threshold. We have also modified a paragraph that discusses the clinical relevance of the basic science findings described in our introduction. We have made some additional small edits to wording and phrasing in the introduction to clarify the aims of our study.2. Consider adding more literature that reports a biochemical explanation for studying the pattern and prevalence of tobacco and other related products among seizure patientsWe thank the editor for this helpful comment. Our preliminary searches on this topic did not reveal studies reporting data on a biochemical cause of increased smoking rates in people with epilepsy or seizure. Our rationale for studying this topic is related to the epidemiologic data suggesting that people with epilepsy may smoke with increased rates. This could be hypothesized to be either due to effects of having epilepsy such as increased rates of comorbid mental illness, social factors such as lower socioeconomic status, or due a shared diathesis for addictive behavior and seizures due to the behavior of pathological neural networks in the brain. We believe that this is an open question and we hope that our systematic approach to scoping the relevant literature may reveal further studies that comment on this question. For now, we will further describe the epidemiologic finding that serves as our rationale for our study. If we find additional studies supporting increased rates of smoking in people with epilepsy, particularly from different geographical reasons, we will describe this trend and any relevant data on the hypotheses mentioned above in the results and discussion sections of the manuscript that will report this study.We have added two sentences to the second paragraph of the introduction/rationale section describing tends of smoking rates amongst people with epilepsy in the United States.1. Please provide more clarification on the study population, why to include children? when the objective is to see the pattern of tobacco and smoking?We thank the editor for this helpful comment. Our aim is to be as inclusive as possible to systematically scope the published literature on smoking, vaping, tobacco, nicotine use, and epilepsy or seizures. We do appreciate that inclusion of both adult and pediatric patients introduces a heterogeneity to our study. However, we believe that including pediatric studies is additive. Prelimary search identified additive studies pediatric population, including data on seizures provoked by nicotine and on treatment of ADSHE. We believe that conducting a broad scoping review will be most useful to framing what is known on our topic of interest and informing further research.We have added a paragraph describing our rationale for including both adult and pediatric patients to our section \"Stage 2: Identifying relevant studies\"2. Elaborate more on the eligibility criteria , and provide a rationaleWe will include studies from all years available in the individual databases (this might be different for each one). We will include English Language studies. Our first paragraph of the stage 2 section described publication status to be included. We have added \"Studies without an available English language article will be excluded.\" To the text of our identifying relevant studies section. \"Records must have an available English language article to be included for data extraction.\" is also included in the \"Context\" section of our Population-Concept-Context Table (table 1). We have added a sentence to the first paragraph of the stage 2 section stating that we will include studies from all years included in relevant databases.3. How are you planning to handle the huge grey literature?Thank you for this helpful comment. We have revised our plan for the grey literature. We will limit inclusion of grey literature to the conference abstracts and clinical trial protocols identified by our search strategy. We believe that this approach is reasonable and that our inclusive scoping review of the academic literature will identify what is known on our topic of interest.We have added a sentence to step 3 of table two stating how we will limit the our inclusion of the grey literature on this topic.4. Provide a still more comprehensive search strategy.Thank you for this comment. We have included a three step description of our search strategy in table 2. We describe our formal search of the literature in the search strategy section of our paper. We include an OVID MEDLINE example search strategy. We believe that our search could be replicated by a medical librarian with appropriate training and experience. In order improve our communication of the search strategy, we will move the MEDLINE search strategy from Appendix 1 to Figure 1 in the body of the manuscript.We have moved the MEDLINE search strategy from Appendix 1 to Figure 1.5. Why no efforts are made to access the quality of included studies using a more accepted tool like the CASP checklist?Thank you for this helpful comment. Our original plan was to use the JBI checklists only if 5 or more studies of a single type were identified. We recognize that our review will be improved by systematic critical appraisal and we will now plan to use the JBI checklists for every article identified. In making this decision we reviewed both of CASP checklists and JBI checklists. While both are excellent tools, we are opting to use the JBI checklists as they include only multiple choice fields without free text. This will improve our ability to synthesize this data in a table or figure.We have edited a sentence in the third paragraph of our Stage 5 section of the manuscript describing our plan.6. Including all types of epilepsies and investigating on all patterns of tobacco use including all possible literature sources? kindly provide a rational for including all epilepsy types and tobacco use patterns? why not focus on a specific type?Thank you for this helpful comment. Our review aims to systematically scope what is known about the effects of tobacco use, vaping, and nicotine related to seizures and epilepsy. Our preliminary search, described in step 1 of our search process table (table 2), demonstrated that the literature on this topic is highly heterogeneous and data on any given type of epilepsy or tobacco use pattern would be limited. By conducting an inclusive review, we believe we can better define the landscape of what is known on these topics. This scoping review may identify areas that could benefit from subsequent systematic review and/or metanalysisWe have added a sentence to the second paragraph of the Stage 2 section of our manuscript describing our rationale for including all epilepsy types and tobacco use patterns.7. Expand 'Tobacco products' in the search strategy thereby the authors don't miss out on any of the types that are available?Thank you for this helpful comment. We agree that this would improve our search strategy.We have added a sentence to the second paragraph of our search strategy section describing this change. We have updated Figure 1 to include these terms in our search.8. How are you planning to discuss the results? are any frameworks are planned to be used? if so do mention the framework that is planned to be adoptedThank you for this helpful comment. Our review will include a discussion section. We will discuss the result of our review within the context of related research in the field of epilepsy. We will highlight important or surprising findings from our results. We will discuss additional research questions identified by our review. We will also discuss the limitations of our review and comment on the quality of evidence identified. This discussion will be informed by the PRISMA-ScR checklist. We have added to the text of the Stage 5 section \"Our manuscript will include a discussion section that will highlight important and or surprising results from this review, discuss additional research questions identified, discuss the limitations of this review, and comment on the quality of the evidence identified.\" We have also added \"and discussion\" to the first sentence of the Stage 5 section of our manuscript to clarify that the PRISMA- ScR checklist will be used to inform the writing of our discussion section in addition to our results section.I do value the importance of smoking in epilepsy pathogenesis and pharmacotherapy and would like the authors to add another question: the impact of passive smoking during pregnancy on thr incidence of epilepsy development in offsprings via retrospective evaluation.We thank the reviewer for this input. We agree that the neurologic outcomes of children of mothers who are exposed to passive smoking during pregnancy is an important topic that could benefit from further research. However, we have chosen not to include the effects of smoking on epilepsy outcomes in children of mothers who smoke in this review. Our review is quite broad and seeks to scope a body of literature to address multiple questions. We are concerned that adding this as an additional question would limit our ability to synthesize evidence and discuss our results in a single manuscript.The scoping review protocol was prepared according to the standardized method stipulated by JBIM. The review objectives are all clear and well defined. Just one suggestion, if the keyword for Tobacco should expand: 'Tobacco products' to ensure that the authors won't miss any kind of specific tobacco products that used in other studies from local settings such as kretek, Shisha, Bidis. The rest is all good and clearly written.Thank you for this helpful comment. We agree that this would improve our search strategy.We have made the changes described above. AttachmentResponse to Reviewers epilepsy and smoking.docxSubmitted filename: Click here for additional data file. 20 Jun 2023How do smoking, vaping, and nicotine affect people with epilepsy and seizures? A scoping review protocolPONE-D-22-27041R1Dear Dr. Narrett,We\u2019re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you\u2019ll receive an e-mail detailing the required amendments. When these have been addressed, you\u2019ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they\u2019ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Sathish RajaaAcademic EditorPLOS ONEAdditional Editor Comments :Dear [Author's Name],I hope this email finds you well. I am writing to inform you about the status of your manuscript, titled \"How do smoking, vaping, and nicotine affect people with epilepsy and seizures? A scoping review protocol\", which you submitted to our esteemed journal Plos one. As an Academic Editor, I am pleased to inform you that your manuscript has successfully completed the revision process and has now entered the peer review stage.I want to express my appreciation for the thorough revisions you have made in response to the reviewers' comments. After carefully evaluating the revised manuscript, I am pleased to inform you that the reviewers have expressed their satisfaction with the changes made. They have acknowledged the improvements and believe that your manuscript is now ready for publication in its current form.Please note that the acceptance is conditional upon successfully completing the remaining editorial and production processes. Our editorial team will now work diligently to move the manuscript forward, ensuring that all necessary steps are taken to prepare it for publication.Once again, I want to congratulate you on the successful revisions and the acceptance of your manuscript. I appreciate your dedication and hard work throughout the peer review process. Your research will undoubtedly enrich the scientific discourse within your field.Thank you for choosing Plos one as the outlet for your important research.Best regards,Sathish RajaaReviewers' comments:Reviewer's Responses to Questions <font color=\"black\"> Comments to the Author1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions? </font> The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.Reviewer #1:\u00a0Yes********** <font color=\"black\"> 2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses? </font> The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions  to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.Reviewer #1:\u00a0Yes********** <font color=\"black\"> 3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable? </font> Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.Reviewer #1:\u00a0Yes********** <font color=\"black\"> 4. Have the authors described where all data underlying the findings will be made available when the study is complete?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data\u2014e.g. participant privacy or use of data from a third party\u2014those must be specified. </font> The Reviewer #1:\u00a0Yes********** <font color=\"black\"> 5. Is the manuscript presented in an intelligible fashion and written in standard English? </font> PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1:\u00a0Yes********** <font color=\"black\"> 6. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.You may also provide optional suggestions and comments to authors that they might find helpful in planning their study. </font> Reviewer #1:\u00a0I value your addressing of my feedback comment and look forward to getting it published. Thank you for the chance.********** <font color=\"black\"> 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose \u201cno\u201d, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. </font> Yes:\u00a0Mohamed MostafaReviewer #1:\u00a0********** 26 Jun 2023PONE-D-22-27041R1 How do smoking, vaping, and nicotine affect people with epilepsy and seizures? A scoping review protocol Dear Dr. Narrett:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofDr. Sathish Rajaa Academic EditorPLOS ONE"}
+{"text": "The crystalline phase and elemental composition of the synthesized particles were identified by X-ray diffraction analysis, Raman spectroscopy and Energy dispersive analysis. As the arc discharge current was raised from 2 to 4\u00a0A, two notable changes occurred in the synthesized particles: the Cu/O ratio increased, and the particle sizes decreased. At 4\u00a0A, the synthesized particles were from 30 to 80\u00a0nm in size and had a spherical shape, indicating an increase in the amount of cuprite (Cu2O) phase. The optical band gap of the aqueous solutions of copper oxide particles also increased from 2 to 2.34\u00a0eV with increasing synthesis current from 2 to 4\u00a0A, respectively. This suggests that the proposed synthesis method can be used to tune the band gap of the final material by controlling the Cu/O ratio through the current of arc discharge. Overall, this work demonstrates a novel approach to the synthesis of copper oxide nanoparticles with controllable CuO/Cu2O/Cu ratios, which has the potential to be useful in a variety of applications, particularly due to the significant enhancement of photocatalytic abilities and widen the working spectral range.This work presents a one-step controlled method for the synthesis of copper oxide nanoparticles using an arc discharge in deionized water without subsequent thermal annealing. The synthesis conditions were varied by changing the arc discharge current from 2 to 4\u00a0A. Scanning electron microscopy images of samples synthesized at discharge current of 2\u00a0A revealed the formation of tenorite (CuO) nanopetals with an average length of 550\u00a0nm and a width of 100\u00a0nm, which had a large surface area. Arc discharge synthesis at 3 and 4\u00a0A current modes provides the formation of a combination of CuO nanopetals with spherical cuprite (Cu Based on metal oxides, different semiconductor architectures have been developed, which allows them to be used in various interdisciplinary areas4. Copper oxide nanoparticles have shown great potential for applications in medicine7, agriculture10, and semiconductor devices12. One of the most important factors influencing the properties and application of copper oxide nanomaterials is the synthesis of various shapes and structures on their basis. Thus, the most popular synthesized structures are nanowires14, nanoflowers16, and spherical nanoparticles17, which are used as efficient photocatalysts18, gas sensors20, and supercapacitors21. Despite the low toxicity of copper oxide22, the synthesis of particles often includes toxic compounds, especially when using a reducing agent in chemical methods23. Compared with common methods for the copper oxide nanoparticles synthesis, such as chemical vapor deposition24, laser ablation25, sol\u2013gel method26 and biological synthesis27, in-liquid plasma is of particular interest because of the simple working process. The study of in-liquid plasma can demonstrate new interactions between liquid and low-temperature plasma as a new approach to better understand the physical mechanisms of complex plasma systems, the relevance of which is demonstrated in the Plasma Roadmap29. This method also has the advantage of being a low cost process, since plasma in liquid does not require expensive equipment such as special vacuum chambers and gas lining systems with anti-corrosion materials.Metal oxide nanomaterials are becoming increasingly popular due to their physicochemical, electrical and optical properties30. For example, in reference31, it was demonstrated that by using deionized water as a dielectric medium, spherical CuO nanoparticles were obtained. However, when water was replaced with an argon gas medium, CuO nanowires were formed. In additon, Yang et al. claim the advantage of using pure water medium  for the green synthesis of copper oxide particles at room temperature through the mechanism of water ionization and subsequent formation of copper hydroxides and then oxides32.It should be noted that one of the main criteria in the synthesis of copper oxides by an arc discharge besides the electrodes and discharge parameters is the environment around the discharge zone, which can determine the structure, composition and even morphology of the resulting materials. In many studies of electric discharge, water was used as a liquid media due to its unique physicochemical properties and accessibility33 it was shown that increasing oxygen pressure lead to a decrease in the cuprite (Cu2O) phase and the prevalent formation of tenorite (CuO). Using this experience it is reasonable to add an additional source of oxygen to in-liquid plasma medium34.One of the common ways to control the phase and composition of the synthesizing copper oxide in gaseous medium usually consists of a variation of the Ar/O2 ratio during arc discharge synthesis. For instance, in ref.35. In36, the authors, using a spark discharge in water, managed to control the sizes of the synthesized copper and copper oxide particles by adding HCl in small concentration adjusting the electrical conductivity of water. Considering these techniques one should take into account the energy efficiency of the synthesis process, since spark discharge requires higher voltages as compared to arc discharge process. Moreover, the use of electrolytes can significantly stabilize the arc discharge in a liquid, but they lead to a complication of the reaction, introducing many side electrochemical reactions30. Therefore, the proposed technique based on arc discharge in deionazed water is energetically efficient, easy, eco-friendly and fast way to produce copper oxide nanoparticles.It should be noted that copper nanoparticles can also be synthesized using different regimes of discharge. For instance, recent paper of Efimov et al. presents the synthesis of copper oxide nanoparticles using so-called dry aerosol jet printing based on spark discharge process37. In particular, when using an arc discharge in a liquid, the advantage of use of small currents of several amperes39 has been reported, since the arc discharge generates a high temperature, which can lead to erosion of metal electrodes. Changes in the current during an arc discharge process can lead to the predominance of various processes in the liquid itself, specifically different reactions of ionization and splitting of water molecules41, which can correspondingly affect the composition and structure of the synthesized particles. Recently, studies have been carried out on obtaining particles from electrodes directly without the use of electrolytes and reducing agents using plasma in water42. A discharge in a liquid medium with oxygen content makes it possible to oxidize metal particles without using thermal annealing after synthesis, which makes it possible to control the synthesis of monodisperse nanoparticles of oxides not only of copper, but presumably of many other metals.It has been reported that the interaction of the liquid with plasma leads to the formation of reducing agents, which allows to reduce the metal ions faster2O phases of oxidized Cu nanoparticles exhibit improved photocatalytic activity under visible light. Therefore, the construction of Cu/CuO/Cu2O heterojunctions is an attractive approach for a wide range of environmental applications43.Among the variety of metal nanomaterials, Cu-based nanostructures have shown great promise for industrial and environmental applications. However, the poor photocatalytic performance of single-phase Cu nanomaterials limits their effectiveness. To address this issue, the development of a junction combining two or three phases with different bandgaps has been proposed. Such junctions would significantly enhance photocatalytic abilities by promoting efficient charge separation and extending the photoexcitation range. Recent research has shown that the CuO and CuIn this study, arc discharge plasma between water-immersed copper electrodes was used as promising and simple process for producing copper oxide particles, where water acted as an oxygen source as well as a dielectric medium. The process is environmentally friendly as no aggressive gases or chemical additives such as electrolytes and reducing agents are used. To obtain an arc discharge in water, a power source with capacity of 1 to 70 \u03bcF was used. The arc discharge current was the main parameter that changed the conditions of particle synthesis. In this case, the arc discharge current varied from 2 to 4 Amperes. Copper oxide particles were synthesized from the electrode directly using an arc discharge in water. The workflow was technologically simplified, since the preparation of particles was carried out in one synthesis reactor, without any additives and subsequent thermal treatment. This method made it possible to synthesize copper oxide particles using relatively low arc discharge currents in water without subsequent annealing and to control the oxidation of copper particles during (in situ) synthesis.44. Deionized water with a resistivity of 18.2 M\u03a9*cm was obtained using a Sartorius arium 611DI instrument. The diagram of the arc discharge system is shown in Fig.\u00a0An arc discharge system in deionized water was used to obtain copper oxide particlesThe plasma of a pulsed arc discharge in deionized water is created by the energy of capacitors located in the power source. The varied technological parameter of synthesis was the arc discharge current. With the same configuration of copper electrodes, currents of 2 A , 3 A  and 4 A  were passed. The voltage was applied until the breakdown current occurred with separated electrodes. To start the discharge, the electrodes were placed in direct contact without a gap between them. When the electrodes were torn off, a breakdown discharge occurred. After the discharge, the distance between the electrodes was controlled. The working cycle of particles synthesis was 10\u00a0min. An electromagnetic vibrator (50\u00a0Hz) was used to initiate the cyclic movement of the electrodes. The rate of powder formation during synthesis is 12\u00a0mg/min at 2\u00a0A, 83\u00a0mg/min at 3 A, 97\u00a0mg/min at 4\u00a0A. As a result of the experiment, a colloidal solution was formed  and SEM on a Quanta 200i 3D complex. Structural properties were studied using Raman spectroscopy using a Solver Spectrum spectrometer (NT-MDT) in 180\u00b0 reflection mode. The excitation source was a laser with a wavelength \u03bb\u2009=\u2009473\u00a0nm. The diameter of the laser spot on the sample was\u2009~\u20092\u00a0\u03bcm. To carry out studies by scanning electron microscopy and Raman spectroscopy, samples were deposited from a colloidal solution onto the surface of a c-Si film and glass, respectively. The crystalline phases of particles samples were studied using X-ray diffraction analysis on a Rigaku MiniFlex 600 X-ray spectrometer with copper radiation (CuK\u03b1). The recording modes are as follows: X-ray tube voltage 40\u00a0kV, tube current 15\u00a0mA, goniometer movement step 2\u03b8\u2009=\u20090.02\u00b0. Phase analysis was performed using the PCPDFWIN program with the PDF-2 diffraction database. To determine the optical properties of the colloidal solution, the optical transmission spectra were studied using a Shimadzu UV-3600 spectrophotometer.During the synthesis of copper particles by an arc discharge in water, a gradual color change was observed from light brown in low-current mode 2A to dark green in synthesis at 4A. Changes in the color of the colloidal solution at the stages of synthesis at different current modes are shown in Fig.\u00a045. As the current increases to 3A and 4A, the intensity of the metallic copper peaks increases and a characteristic peak at 74.3\u00b0 for pure copper phase becomes more prominent45. In the case of mode 2A, the peaks characteristic of Cu2O at 36.37\u00b0, 42.26\u00b0, 61.36\u00b0, 73.664\u00b0 and 77.38\u00b0 correspond to the planes (111), (200), (220), (311) and (222) of the cubic cuprite phase, respectively, and are in good agreement with JCPDS 78-207646. As the current regime increases, a peak appears at 29.51\u00b0 corresponding to the (110) plane, which also belongs to the Cu2O phase. The most intense phase in the low current mode (2A) is the CuO tenorite, which decreases in intensity with an increase in the arc discharge current. Crystallographic orientations arose at 2\u03b8 values of 32.6\u00b0, 35.5\u00b0, 38.6\u00b0, 48.8\u00b0, 53.5\u00b0, 58.2\u00b0, 65.9\u00b0, 67.82\u00b0, 72.17\u00b0, and 75.1\u00b0, respectively, which corresponds to the (110), (111), (111), (202), (020), (202) (113), (202), (311), and (004) planes of the CuO monoclinic tenorite phase structure, and agrees well with the previously published data (according to JCPDS card 48-1548)47.The crystal structure and purity of the freshly prepared copper oxide particles were investigated by X-ray diffraction analysis (Cu-K\u03b1 radiation). Figure\u00a046:To evaluate the crystallite size of our samples when changing the current regime, the Scherrer equation was used48 has established that particles with such a morphology can be identified as tenorite (CuO) phase.The morphology of the synthesized copper oxide structures was characterized using a scanning electron microscope (SEM). As shown in Fig.\u00a0With an increase in the current regime to 3 A, the structure retained the shape characteristic of CuO. Figure\u00a0Figure\u00a02O).The elemental composition of the synthesized particles was determined using energy dispersive analysis Fig.\u00a0c,f, i. T2O complex, the Raman spectra were measured 50. As can be seen from the equation, there are 12 zone-central optical phonon modes in the pure CuO phase. Among these 12 modes, there are three acoustic modes (Au\u2009+\u20092Bu), six infrared active modes (3Au\u2009+\u20093Bg), and three Raman active modes (Ag\u2009+\u20092Bg)51.To additionally confirm the composition of synthesized particles of the CuO/Cured Fig.\u00a0. As it w\u22121. The peak at 286\u00a0cm\u22121 can be assigned to the Ag mode, and the peaks located at 330\u00a0cm\u22121 and 620\u00a0cm\u22121 can be assigned to the B1g and B2g modes, respectively52. According to theoretical calculations, these oscillations correspond to the motion of only oxygen atoms in the CuO lattice, and for the Ag mode, the oscillations occur along the b axis, while for the Bg mode, the oscillations are perpendicular to the b axis. A slight trend below 200\u00a0cm\u22121 can be deconvoluted into two peaks at about 107 and 145\u00a0cm\u22121 which are characteristics of Cu2O. While the broad peak at\u2009~\u2009560\u2013570\u00a0cm\u22121 can be possibly due to the second order of the Ag mode (peak at 286\u00a0cm\u22121).Figure\u00a02O has a cuprite cubic structure, space group 2O, 18 phonon modes are expected according to group theory53.Cu2g is Raman-active. A T2g mode is a threefold degenerated mode, which is symmetric with regard to one of the fourfold rotation axis. The \"g\" shows that there is an inversion center which is kept during the vibration. This mode arises as a result of the motion of two oxygen sublattices relative to each other, while the copper sublattice remains fixed (immobile). However, the appearance of additional Raman peaks can be due to defects in a pure crystal and as a result of overtones and mode combination.And only one mode, T\u20131, indicating the presence of the Cu2O phase in the powder composition, which is in good agreement with the XRD and EDS. The three intense peaks two of which are slightly asymmetric can be deconvoluted into 5 bands with positions at 97, 109, 145\u00a0cm\u22121, which correspond to T2u, Eu, T1u modes of Cu2O, respectively, and 197 and 218\u00a0cm\u22121 which are possibly the second order of the peaks at 97 and 109\u00a0cm\u22121. Peaks at 410 and 520\u00a0cm\u22121 are also due to Cu2O vibrations, particularly the band at 410\u00a0cm\u22121 is considered as fourth-order overtone, while 520\u00a0cm\u22121 corresponds to T2g Raman active mode. Less intensive peaks at 287, 339\u00a0cm\u22121 indicate the presence of CuO phase. While rather broad band at about 623\u00a0cm\u22121 can be attributed to both CuO (Bg mode) and Cu2O (T1u mode). The peak at 145\u00a0cm\u22121 corresponding to the T1u cuprite mode can appear in the Raman spectrum as a result of oxygen vacancies56. The low intensity of the Raman peaks of copper oxides may indicate the presence of a significant amount of the metal phase in the composition of the samples, which is also confirmed by the XRD data.Figure\u00a02O phase\u2014peaks at 105, 145, 192, 214, 410 and 770\u00a0cm\u22121. A low-intensity broad peak at 290\u00a0cm\u22121 can be caused by the presence of Cu2O and/or Cu(OH)2, which is quite understandable, since the synthesis of nanoparticles is carried out in water. The presence of the copper hydroxide phase is also indicated by a peak in the region of 490\u00a0cm\u22121. The broad peak in the region of 630\u00a0cm\u22121 can be decomposed into two components: at 620\u00a0cm\u22121 corresponding to CuO and at 630\u00a0cm\u22121 characteristic of the Cu2O phase.The Raman spectrum of samples obtained at 4A 2 versus energy (h\u03bd) for determining the optical band gap (Eg) is shown in Fig.\u00a0The optical properties of the synthesized colloidal solutions of copper oxide were analyzed using a Shimadzu UV-3600 spectrophotometer in the visible range to calculate the light absorption zone edge and the optical band gap. Figure\u00a02O are 1.24\u00a0eV and 2.47\u00a0eV, respectively58. However, that the band gap of copper oxide can be influenced by factors such as morphology and size. According to57, the band gap of CuO nanopetal is about 1.73\u00a0eV, which is higher than that of bulk CuO, while in ref.59 authors claim that a decrease in the size of crystallites can also increase the band gap. And as was observed in our experiment, an increase in current value leads to a decrease in crystallite sizes of all forming phases\u2014CuO, Cu2O and Cu. In addition, the presence of the Cu2O phase in the synthesized samples, which was revealed by XRD, EDS, and Raman data, can further contribute to increasing the band gap. Thus, it can be assumed that the band gap of the synthesized copper oxides is determined by three factors CuO/Cu2O phase content, changes in morphology, and a decrease in crystallite sizes as the current value increases.It is worth noting that the typical band gaps for bulk CuO and Cu2O/CuO/Cu phases with different ratios depending on discharge current mode. The band gap of the aqueous solutions of copper oxide particles increased with increasing synthesis current, indicating the proposed method's ability to tune the band gap of the final material by controlling the Cu/O ratio, morphology and crystallite sizes. The combination of CuO/Cu2O nanoparticles offers several advantages, particularly it can improve the efficiency of the photocatalytic processes by providing a synergistic effect between the two types of nanoparticles. This synergistic effect can enhance the photocatalytic properties of the system, such as improved light absorption, charge separation, and redox reactions, resulting in higher efficiency and effectiveness in various applications, including water treatment, air purification, and solar energy conversion.In the work, the one-step method of synthesizing copper oxide nanoparticles using an arc discharge in deionized water without subsequent thermal annealing has been presented. The study varied the synthesis conditions by changing the arc discharge current, resulting in nanoparticles with varying sizes and shapes. Elemental composition as well as Raman and XRD analysis showed the formation of combination of Cu"}
+{"text": "Over recent decades, different types of animal models, from arthropods to primates, have been applied to neuroscience research, making irreplaceable contributions to reveal the neural basis of various behaviors. Aves are one of the most prosperous amniotes  globally, which has evolved in parallel with mammals. Although avian and mammalian brains are constructed in very different ways, the sensory information processing, cognition, behavior, and related neural control pathways of some bird species are highly similar to those of mammals, including primates and even humans. For example, the brains of birds and mammals have conserved visual and auditory pathways  Species that communicate primarily or only through auditory signals over long distances (separating the sender and receiver). (2) Species that need to converge or diverge from other group members by modifying their vocal signals, such as dolphins, seals, bats, elephants. (3) Species that would benefit from increasing the complexity of vocal signals, such as songbirds and whales. The perspective of this article provides a new integrated framework for understanding the evolution of vocal production learning.Vocal production learning is a kind of information communication ability that only few animal species possess. It refers to the behavior of animal individuals forming new vocal signals or modifying existing vocal signals based on auditory feedback from other individuals' vocalizations and their own vocalizations. Besides humans, the most striking examples of vocal production learning are songbirds, parrots, and hummingbirds in birds, and cetaceans and bats in mammals Beecher, . In two Zhang, Zhou et al. is also about animal vocal learning, but focuses more on the comparison of similarities between songbird singing and human speech. The article begins with an overview of the current understanding of mammalian and avian vocal learners, including newly discovered potential vocal learners. Based on existing research data, the following part of the paper focuses on the rare similarities in vocal learning between humans and songbirds, which are known to have different evolutionary origins. The song learning process of young songbirds is similar to the speech learning process of human infants, including the sensory stage and the sensorimotor stage, which require the participation of auditory feedback. Additionally, humans and some songbirds, such as zebra finches, have similar vocal learning critical periods and have greater learning abilities in infancy. Another important feature of human language is its complex grammatical structure. Some species of songbirds, such as Bengalese finches, can flexibly and purposefully change the order of syllables in their songs, just like humans control the order of words in language. Although there are insurmountable differences in the structure and cell types of the cerebral cortex between songbirds and humans, the coordination and interaction between the forebrain vocal motor pathway and the brainstem innate vocal pathway are indispensable for the production of autonomous vocalization, and the vocal learning pathway and the vocal motor pathway have similar neural connections, and both receive auditory information from the auditory system. This article further compares the neural basis of human speech and songbird singing, and in detail compared the similarities of projection connections, functions, neural activities, cell types, genome and transcriptome between each human speech-related brain region and songbird song-related neural nucleus in the brainstem innate vocal control pathway, forebrain vocal motor pathway and vocal learning pathway, including more recent findings. The article concludes with outlining, prospective topics of relevance for the future research.Next, the review presented by Zhang, Sun et al. to this Research Topic is the first evidence to prove that E2 can regulate the excitability of projection neurons in the song premotor nucleus robust nucleus of the arcopallium (RA) in adult songbirds. In this study, whole-cell patch-clamp recordings of adult male zebra finch RA projection neurons were performed and combined with pharmacological detection. The findings indicated that E2 has the ability to lower the spontaneous and evoked action potential firing rate of RA projection neurons, induce hyperpolarization of the resting membrane potential, and decrease the membrane input resistance. At the same time, it was found that GPER agonist G1 can mimic the action of E2 on RA projection neurons, while GPER antagonistist G15 can block the effect of E2, indicating that E2 reduces the excitability of RA projection neurons via GPER. These results contribute to understanding the regulation of E2 on the intrinsic membrane properties of songbird RA projection neurons and its receptor mechanisms.Estrogen in the animal brain, mainly estradiol 17\u03b2-Estradiol (E2), is converted from androgens under the action of aromatase, and can affect brain function and behavior  is an evolutionarily conserved neurotransmitter present in the central nervous system of all vertebrates. It is now known that 5-HT is widely involved in the regulation of mammalian brain functions, including cognition, behavior, and emotion (Bacque-Cazenave et al., WM: Funding acquisition, Project administration, Resources, Writing \u2013 original draft, Writing \u2013 review & editing."}
+{"text": "Cigarettes, despite being economically important legal consumer products, are highly addictive and harmful, particularly to the respiratory system. Tobacco smoke is a complex mixture containing over 7000 chemical compounds, 86 of which are identified to have \u201csufficient evidence of carcinogenicity\u201d in either animal or human tests. Thus, tobacco smoke poses a significant health risk to humans. This article focuses on materials that help reduce the levels of major carcinogens in cigarette smoke; these include nicotine, polycyclic aromatic hydrocarbons, tobacco\u2010specific nitrosamines, hydrogen cyanide, carbon monoxide, and formaldehyde. Specifically, the research progress on adsorption effects and mechanisms of advanced materials such as cellulose, zeolite, activated carbon, graphene, and molecularly imprinted polymers are highlighted. The future trends and prospects in this field are also discussed. Notably, with advancements in supramolecular chemistry and materials engineering, the design of functionally oriented materials has become increasingly multidisciplinary. Certainly, several advanced materials can play a critical role in reducing the harmful effects of cigarette smoke. This review aims to serve as an insightful reference for the design of hybrid and functionally oriented advanced materials. For many years, CA is used as a cigarette smoke filter, but there are recent developments in absorbent materials such as zeolite and its derivatives, AC composites, modified graphene, MIPs, various composites, and hybrid materials. The question is how to design the next generation of highly selective, emerging advanced materials that can protect smokers from the harmful components of cigarette smoke. The six largest tobacco producers include China, India, Brazil, the United States, Indonesia, and Malawi. Currently, > 120 countries cultivate tobacco. Although the smoking trend appears to be declining in most countries, the absolute number of smokers remains high, fueled by nicotine addiction and population growth. Tobacco consumption poses significant risks to human health. Despite the implementation of tobacco control measures, the number of smokers, including young people, remains a cause of concern. Although tobacco sales have decreased slightly in specific regions owing to global tobacco control efforts, sales continue to increase in most areas.  The detrimental effects of smoking can be ascribed to the numerous toxic substances present in cigarette smoke, including nicotine, polycyclic aromatic hydrocarbons (PAHs), tobacco\u2010specific nitrosamines (TSNA), hydrogen cyanide (HCN), carbon monoxide (CO), and formaldehyde , is associated with various health risks such as respiratory and cardiovascular diseases, diabetes, and cancer. Smoking can reduce life expectancy by at least ten years. Tobacco smoke has emerged as a significant health hazard to humans with far\u2010reaching consequences for individuals, families, and society.1 The e Figure\u00a0. These c1.2The World Health Organization has recommended six MPOWER measures to combat the global tobacco epidemic. Various measures can be adopted to mitigate the negative effects of tobacco use. These include closely monitoring tobacco usage, implementing preventive measures, providing support for those who wish to quit smoking, educating people about the high risks associated with smoking, increasing tobacco taxes, and implementing law enforcement rules on tobacco promotion and advertising. While many countries have made progress in curbing smoking, some countries are yet to address emerging nicotine and tobacco products or develop effective regulations. Currently, the primary methods for reducing harm to the tobacco industry include tobacco cultivation, leaf processing, cigarette processing, and new cigarette filters.1.2.1 In conclusion, various measures have been implemented to reduce nicotine and tar production in tobacco leaves, resulting in a raw material with fewer harmful substances, particularly low tar contents, for cigarette production.Tobacco leaves, a raw material for cigarettes, produce tar and other harmful components when burned. Agronomic measures can be implemented to promote desired nicotine concentrations. In breeding tobacco varieties, it is necessary to cultivate varieties with low nicotine and tar contents but sufficient aroma, as well as other varieties that meet specific requirements. Scientists have conducted studies on the synthesis of tobacco alkaloids using molecular genetic approaches. During tobacco cultivation, nicotine concentrations can be affected by applying nitrogen fertilizers, adjusting planting density, inhibiting suckers, and changing harvesting methods.6 In c1.2.22 technology during tobacco leaf treatment, solvent extraction, and low\u2010temperature treatment and additives such as combustion\u2010supporting agents, antioxidants, adsorbents, and catalytic oxidants in cut tobacco. These techniques aim to minimize the release of harmful components and enhance smoking experience.During cigarette manufacturing, factors such as curing techniques, fermentation, pH, humectants, and additives, can affect nitrosamine formation in tobacco. To reduce the release of harmful components during smoking, researchers have used supercritical COperience.71.2.3 Through continuous efforts, cigarette filters can reduce the levels of toxic and carcinogenic substances in cigarette smoke. Studies have revealed that modified filters containing deoxyribonucleic acid (DNA) can significantly reduce PAHs in cigarette smoke without affecting nicotine delivery.Over the last few decades, cigarette manufacturers have developed various filters to minimize exposure to harmful substances. Different types of adsorbent materials have been developed for commercial cigarette filters to remove tar and other harmful particles. Typically, the materials used for making a cigarette filter should be loose, porous, and with good air permeability and filtration efficiency. These materials include sponges; resins; various forms of paper; natural fibers such as cotton, callus, silk, and flax; synthetic fibers such as cellulose esters and ethers; and other functional absorbents such as activated carbon and zeolite.8 Thro1.3\u22121 is internationally recognized to be relatively safe for smokers. However, quitting smoking can result in withdrawal symptoms such as increased negative reactions  and decreased positive reactions. Therefore, to reduce the harmful effects of tobacco on smokers, it is important to develop adsorption materials that can effectively and selectively lower other toxic substances in cigarette smoke without reducing nicotine content. Nevertheless, the most effective approach to minimize the health hazards of tobacco is to quit smoking. This review aims to provide a systematic summary of adsorption materials, published before 2022, for capturing hazardous compounds from cigarette smoke.Tobacco with tar levels below 15 mg cigaretteeactions.10 The2 During tobacco combustion, various gaseous products and suspended particulate matter are produced.Figure The \u201cHoffmann analytes\u201d are recognized by regulators in most countries and regions around the world as relevant to smoking\u2010related diseases. There are 82 substances in tobacco smoke that are considered harmful. The list of \u201cHoffmann analytes\u201d includes some PAHs, aromatic amines, N\u2010nitrosamines, phenols, low boiling point carbonyl compounds, heterocyclic aromatic amines, etc. Furthermore, Rodgman and Green have summarized a more detailed list. The IARC has evaluated the well\u2010documented risks to humans of 86 carcinogens , cigarette smoke is a complex mixture of >7000 compounds, of which 50 have been identified as carcinogenic.1a Durs Figure\u00a0 in cigar The popular e\u2010cigarette is a novel tobacco vapor product that consists of an electrical heating device, an atomizer, and tobacco capsules containing liquid nicotine. During use, tobacco vapor is produced through indirect heating by passing vapor, rather than direct heating of tobacco. The heating temperature in this process is \u224830 \u00b0C, which produces a distinctively lower yield of harmful smoke components.The major ingredients in cigarette smoke vary according to the pyrolysis temperature, atmosphere, and pH of tobacco leaves.14 The2.1 Nicotine is inhaled with smoke and then quickly distributed to human organs, such as the lung, liver, kidneys, and spleen. It easily passes through the membranes and placenta. Nicotine is a naturally occurring alkaloid consumed by tobacco and other plants for hundreds of years and is one of the world's most widely used psychostimulants. Under physiological conditions, nicotine can cross cell membranes and bind stereospecifically to receptors at neuromuscular, adrenal, and autonomic ganglia junctions. It can cross the blood\u2010brain barrier and is distributed throughout the brain. Even short\u2010term nicotine exposure can cause tachycardia, high blood pressure, nausea, and vomiting. Usually, people resort to e\u2010cigarettes in response to smoking restrictions, assuming that they would be less harmful to human health, but the nicotine concentration in e\u2010cigarettes is much higher than that in regular cigarettes, and the risk is still significant. Clinical and preclinical evidence suggests that adolescent nicotine exposure increases vulnerability to mood and anxiety disorders later in life.The major alkaloids in tobacco are nicotine (3\u2010(1\u2010methyl\u20102\u2010pyrrolidinyl) pyridine; Figure\u00a016 Nic However, there exists another metabolic pathway for nicotine. In this pathway, nicotine is hydroxylated to produce 2\u2032\u2010hydroxynicotine by P450 2A6 and forms an amino ketone NNK (4\u2010(methylamino)\u20101\u2010(3\u2010pyridyl)\u20101\u2010butanone) intermediate. NNK is further metabolized into keto acids. Because nitrosation occurs during the chemical synthesis of NNK, it may be a direct cause of nicotine\u2010induced lung cancer. Nitrosation reactions undergo a reaction in which hydrogen in N\u2014H is replaced by NO, forming N\u2014NO. For secondary and tertiary amines, the oxidative cleavage of C\u2014N bonds can occur, yielding pro\u2010carcinogenic nitrosamines 4\u2010(methylnitrosamino)\u20101\u2010(3\u2010pyridyl)\u20101\u2010butanone (NNK), nitrosamino aldehyde (NNA), and N\u2032\u2010nitrosonornicotine (NNN).Nicotine is rapidly metabolized in the liver Figure\u00a0, and rou20 How2.2 TSNAs are produced in tobacco during both post\u2010harvest processing and cigarette consumption when alkaloids in tobacco such as nicotine, nornicotine, anabasine, and anatabine, react with nitrosating agents. Tobacco products contain eight types of TSNA: NNK, NNN, NNA, NAB, NAT, NNAL, iso\u2010NNAC, and iso\u2010NNAL  are N\u2010nitrosamines found exclusively in tobacco products.23 TSNL Figure\u00a0. TSNA forms adducts with DNA through metabolic activation of nitrosamines, which causes tissue damage and deterioration. This is because, during the metabolism of TSNA, in addition to the formation of DNA adducts, \u2022OH and other reactive oxygen species are also produced, leading to the breakage of single\u2010stranded DNA and causing DNA damage. E\u2010cigarettes and vaping also pose health risks because they contain relatively high concentrations of nicotine and TSNAs. In addition, high levels of TSNAs are detectable in smoking environments, suggesting that non\u2010smokers are also exposed to the dangers of cigarette smoke owing to secondhand smoke.TSNA is highly carcinogenic and can lead to various types of malignancies, including those in the oral and nasal cavities, esophagus, lungs, liver, pancreas, and breasts.25 TSN2.3 The IARC Monographs Program summarizes the carcinogenicity of 60 individual PAHs. Most PAHs are hydrophobic but can pollute water by binding to suspended sediments. Most industrial waste gases and tobacco smoke contain PAHs, which when inhaled, can cause lung and heart diseases. Cigarette smoke contains 16 priority toxicant PAHs  and other carbon\u2010containing materials . Low\u2010temperature combustion, such as that in smoke or forest fires, generates more PAHs than high\u2010temperature furnace combustion.29 The demonstrated that cell wall carbohydrates and lipophilic components in tobacco are primary low\u2010temperature (\u2264600 \u00b0C) PAH precursors. During the carbonization process, the remaining residual solid (char) undergoes chemical transformation and rearrangement, resulting in the formation of condensed polycyclic aromatic structures between 350\u2013600 \u00b0C, which further evolve into PAHs upon heating.McGrath et\u00a0al.33 dem2.43+ center in cytochrome oxidase, which blocks the reduction of Fe3+ to Fe2+ during the oxidation process, leading to the inability of tissue cells in utilizing oxygen and causing hypoxia and asphyxia. HCN is extremely toxic with a minimum lethal dose of 30 mg (considering an adult weighing 60 kg as an example) and a maximum allowable concentration of 0.3 mg m\u22123 in air. Mainstream cigarette smoke contains \u22483200 \u00b5g of HCN per cigarette. Chronic exposure to HCN can harm the central nervous system; cause amblyopia, retrobulbar neuritis, and sterility; and hinder wound healing in smokers. Therefore, reducing the release of HCN from mainstream cigarette smoke is crucial for protecting the health of smokers.HCN is a highly toxic substance and a representative toxicant found in cigarette smoke. HCN can be absorbed through the mucous membranes and inhibits cytochrome oxidase in the respiratory chain. Its toxic mechanism involves a combination with the Feasphyxia.34 HCN2.5 Compared to O2, CO has a higher binding affinity for hemoglobin. This binding results in the formation of carboxyhemoglobin (HbCO), which significantly decreases the oxygen\u2010carrying capacity of hemoglobin, reducing the ability of red blood cells (erythrocytes) to deliver oxygen to tissues. The symptoms of CO poisoning include encephalalgia, dizziness, shortness of breath, weakness, retching, and coma. The use of filter tips and cigarette paper can significantly decrease CO emissions from mainstream smoke.CO is a critically hazardous constituent of cigarette smoke that is poisonous and can cause various diseases, including cancer. CO mainly results from the incomplete combustion of coal, automobile exhaust emissions, natural disasters, and the use of stoves. It should be noted that, when smoking, CO is quickly absorbed into the blood, leading to an increase in blood CO content.35 Com2.6 When cigarettes are burned, large amounts of saccharide substances in cigarettes are pyrolyzed, producing formaldehyde that exists in both mainstream (yields of \u224820\u201360 \u00b5g) and sidestream (yields of 350\u2013450 \u00b5g) smoke. Cigarettes supplemented with sugar continuously increase formaldehyde generation. Notably, the first puff of a cigarette produces unusually high levels of formaldehyde. Studies have indicated that formaldehyde levels in mainstream smoke are affected by factors such as the length of the cigarette rod and smoke accumulation on cigarette filters. Additionally, heat exposure during smoking, during the final puff(s), significantly affects the formaldehyde levels in each puff.Formaldehyde is classified as carcinogen 1 B and germ cell mutagen category 2 by the European Union.38 Whe33.13.1.1Figure Figure\u00a0 Consequently, researchers are exploring approaches to design and synthesize cellulose\u2010modified composite materials to address these issues.Cigarette filters Figure3a are m developed a method for preparing functional porous microspheres by synthesizing a composite of carboxymethyl cellulose (CMC) and cellulose acetate (CA) via double emulsion\u2010solvent evaporation. The researchers also introduced cupric ions, which have a high affinity for HCN, into composite microspheres. The microspheres featured a connected macroporous structure  and graphene oxide (GO), followed by lyophilization , 90.3% , 95.0% (nicotine), and 20.6% (CO). These results indicate that the CSG filter can effectively reduce the harmful constituents of cigarette smoke.Cheng et\u00a0al.44 dev3.1.2 developed a modified natural cellulose Juncus effusus (JE) fiber using polyvinylpyrrolidone (PVP) as a cigarette filter. The PVP\u2010JE filter tips showed superior filtering and adsorption capabilities for PAHs, with an adsorption rate of 61.8%. This is much higher than that achieved with CA fiber tips (39.2%).Natural fibers are widely distributed in nature and are not only abundantly available but also environmentally friendly and inexpensive. Natural fibers have a large specific surface area and internal space, making them potentially suitable for use as adsorbents. Functionalization and modification of natural fiber surfaces are attractive approaches for developing high\u2010value\u2010added plant resource products to achieve sustainable goals. Xu et\u00a0al.45 dev investigated the blocking and filtering capacities of cotton  and zeolites with low Si/Al ratios (such as NaY and NaA). Owing to their unique shape selectivity and abundant active sites, zeolites have been extensively used as sorbents, catalysts, and carriers. Recently, they have been explored in the life sciences for applications such as slow\u2010release, enzyme\u2010mimetic, and antitumor drugs. Zeolites are ubiquitous in daily life and are used for purifying indoor air and softening and decontaminating water, among other applications. One potential application of zeolites is to capture nitrosamines in complex systems Temperature: Generally, increasing the temperature leads to a higher airflow velocity, which can hinder the capture of volatile nitrosamines by most zeolites, although, NaZSM\u20105 is an exception to this trend.52hb) If the zeolite channels are sufficiently wide, the entire adsorbate molecule can be adsorbed. However, for zeolites with narrow channels, only the nitrosamine N\u2014NO group is inserted into the channel while the rest of the molecule remained on the surface.Si/Al ratio: Zeolites contain metal ions on their surfaces, and electrostatic fields within their channels. The N\u2014NO group of the nitrosamine molecules carries a negative charge, making it easier for cations in the zeolite to be attracted for adsorption.52h,i c)+. In basic zeolites with Na+, such as NaZSM\u20105 and NaY, the degradation of volatile nitrosamines starts with the cleavage of the N\u2014N bond in the N\u2014NO functional group through a radical reaction process  and the properties of the zeolites, including their Si/Al ratio, specific surface area, and aperture ratio.55 acid\u2013base, and spatial effects on the adsorption of PAHs by zeolite. They found that the adsorption efficiency of PAHs is significantly increased with the \u03c0\u2014\u03c0 interactions, hydrogen bonding, and hydrophobic effect of functional zeolite. Moreover, the acid\u2010treated natural zeolite showed the best adsorption of PAHs.The removal rate of some PAHs by the modified zeolite exceeded 85%.Researchers also investigated the effects of hydrophobicity,55a ac3.2.2 These mesoporous materials have suitable pore sizes (2.0\u201330.0 nm) and have potential uses as carriers for catalysts, extraction agents, and selective sorbents.Silicate mesoporous materials are attractive because of their high surface areas and large uniform pores, making them desirable for various applications. The silicate/aluminosilicate mesoporous molecular sieve family M41S includes lamellar (MCM\u201050), cubic (MCM\u201048), and hexagonal (MCM\u201041), which was discovered by the ExxonMobil Corporation in 1992.56 The possesses regular and uniform pores and channels with diameters ranging from 15\u2013100 \u00c5. Thus, MCM\u201041\u2010based materials are highly promising for selective adsorption and separation. Zhu et\u00a0al. prepared MCM\u201041 mesoporous zeolite. The mesoporous structure provides sufficient space for capturing large volumes of nitrosamine (such as NNN), thus improving the adsorption efficiency of NNN. The adsorption capacity of the mesoporous zeolite (MZ25\u201012) for NNN is two times higher than that of mesoporous silica (MCM\u201041) and over 10 times higher than that of microporous zeolite (ZSM\u20105). Subsequently, Zhu et\u00a0al. adjusted the curvature of the MCM\u201041 microporous channel. In their study, electrostatic interactions were applied to the TSNA in a solution containing 5% CuO and Al. The composite exhibited excellent performance in various tobacco extract solutions with a TSNA removal rate of 0.31 mg g\u22121.The hexagonal mesophase MCM\u201041 Figure\u00a058] 58 pyrene or phenols, which was owing to \u03c0\u2014\u03c0 interaction between the aromatic modules. Pandey et\u00a0al. inserted an MWCNTs membrane  to synthesize ACS/GO composite material (surface area 7.460 m2 g\u22121)  Figure\u00a0 and founGraphene\u2010based composite materials are receiving research attention and are expected to receive increasing focus in the future due to their outstanding adsorption performances.3.43.4.1 Compared to other porous materials such as AC and zeolites, MOFs have several advantages, including a large specific surface area, adjustable pore size, micro\u2010and mesoporous structures, diversity in pore size and skeleton structure, and tunable pore surface functional groups with unsaturated metal coordination sites. Furthermore, MOFs have high adsorption capacities for many toxic gases at room temperature and atmospheric pressure, providing a competitive advantage for PAHs adsorption. Furthermore, MOFs have the potential to selectively adsorb PAHs because of their superior porosity and strong \u03c0\u2014\u03c0 stacking effects on aromatic hydrocarbons. Zango et\u00a0al. conducted molecular docking studies to investigate the adsorption of PAHs on MOFs and determine the optimal host\u2010guest binding interaction and receptor\u2010binding sites that form the most stable conformation. As shown in FigureMetal\u2013organic frameworks (MOFs) are a type of porous material composed of organic ligands and metal ions through self\u2010assembly, forming a highly crystalline and periodic 3D network structure. Because of the various coordination numbers of different metal ions and the complexity of their coordination with organic ligands, MOFs exhibit a wide range of multidimensional skeleton structures.104 Co demonstrated the preparation  in cigarettes by combining Ce ions with terephthalic acid (TA) (CE\u2010BDC) and then self\u2010assembling them under the template effect of soluble starch. The formation of Ce\u2014O coordination bonds and oxygen vacancies in Ce\u2010BDC MOFs had the ability to convert Ce3+ to Ce4+, and eliminate >90% of \u2022OH. On the other hand, Yang et\u00a0al. prepared MOF@CF filter materials for nicotine adsorption by combining MOFs ) with bamboo\u2010derived cellulose fiber. The UiO\u201066@CF exhibited the best mechanical properties and good recyclability, while also achieving a nicotine adsorption efficiency of 90%. The XPS results indicated that all MOF@CFs had open metal sites that bound to nicotine except for ZIF\u20108@CF. DFT calculations proved that the highest occupied molecular orbital and lowest unoccupied molecular orbital energy difference of UiO\u201066 was 4.9 eV, which was the closest to that of nicotine, making it more favorable for nicotine adsorption.Chen et\u00a0al.107 syMOFs are considered one of the most promising adsorption materials for harmful substances in tobacco because of their tunable pore structures and exceptional physicochemical properties. However, some limitations hinder their practical application, such as weak dispersion forces arising from a large amount of void space and a lack of open metal sites. Additionally, the commercial application of MOFs for adsorbing harmful substances in cigarette smoke is limited owing to the high cost of MOFs materials.3.4.22, CO2, CH4, and others. Additionally, magnetic COFs are highly effective adsorbents for enriching and detecting PAHs in PM2.5, water, and soil.Covalent organic frameworks (COFs) are a type of highly porous materials that consist entirely of organic compounds that are renowned for their exceptionally lightweight properties. Unlike 2D COFs, 3D COFs have a distinct framework that results in a higher specific surface area and a lower crystal density, which makes them more versatile. One of their most significant advantages is their exceptional ability to adsorb gases adsorption capacity, which makes them ideal for storing gases, such as Hd others.109 Ad developed a COF\u2010based magnetic adsorbent , which proved to be highly effective for the extraction of PAHs. The excellent performance of this adsorbent was mainly due to strong \u03c0\u2014\u03c0 stacking as well as hydrophobic interactions. Zhu et\u00a0al. synthesized a clover\u2010shaped nanotitania\u2010functionalized COFs (CSTF\u2010COF) for the dispersed solid\u2010phase extraction of N\u2010nitrosamines in water. It showed excellent extraction ability to N\u2010nitrosamines through hydrophobic, \u03c0\u2014\u03c0 superposition, and hydrogen\u2010bonding interactions.Chen et\u00a0al.110a dt Figure\u00a0 to extra3.4.3\u03c0\u2014\u03c0 stacking, charge\u2010dipole interaction, van der Waals force, and more . MIPs are functional materials with high affinity and selectivity for target molecules. Molecular recognition interactions rely on various non\u2010covalent bond forces, including electrostatic interaction, hydrogen bond, coordination bond between metal atoms and ligands, hydrophobic interaction, re Figure11a.P as the template molecule. The study indicated that the polarity of the functional monomer and crosslinking agents are critical in determining the affinity and retention behaviors and that the cross\u2010linker is more critical than the monomer. Baggiani et\u00a0al. synthesized pyrene\u2010imprinted microbeads with molecular recognition capabilities for PAHs and demonstrated that the molecular recognition of PAHs by MIPs is controlled by the shape and dimensions of the binding sites through hydrophobic interactions. Msagati et\u00a0al. prepared a composite of reduced GO and Pyr\u2010imprinted polymer that could successfully extract PAHs from water samples as a solid phase. Xu et\u00a0al. used NNK as a template molecule to synthesize hollow molecularly imprinted polymer microspheres that showed excellent selectivity, fast mass transfer rate, and efficient adsorption performance, with the adsorption capacity being three times that of the hollow non\u2010imprinted polymer to N\u2010nitroamine. Xie et\u00a0al. synthesized surface MIPs (SMIPs) with SiO2 nanospheres bearing vinyl functional groups that specifically recognize nicotine. The results showed that the SMIPs efficiently and selectively adsorbed nicotine.One of the most significant applications of MIPs is as sorbents for solid\u2010phase extraction. MIPs have been explored for the adsorption of harmful components, such as nicotine and PAHs, in cigarette smoke. In these studies, the harmful components were used as template molecules to prepare the MIPs for use as adsorbents in solid\u2010phase extraction. In 2004, Knopp et\u00a0al.113 fi grafted MIPs with nicotinamide as a template onto the surface of silica gel, obtaining MIP@SiO2, which was used as a filter additive at the interface between the filter tip and tobacco rod to absorb TSNA in mainstream cigarette smoke. The results showed that MIP@SiO2 selectively adsorbed TSNA without simultaneously adsorbing the total PM  can absorb nicotine, PAHs, HCN, CO, and other substances from cigarette smoke. Molecular sieves can reduce the levels of nicotine, TSNAs, and PAHs in cigarette smoke and have a specific adsorption capacity for TSNAs. MOFs, COFs. Notably, MIPs have the potential to selectively adsorb PAHs due to their superior selectivity and strong While significant progress has been made, challenges remain in the development of advanced materials that can effectively reduce the toxic substances in cigarette smoke without significantly affecting smoking satisfaction. It is important to point out that nicotine is an addictive substance in cigarette smoke. If nicotine is removed and reduced indiscriminately along with the well\u2010known carcinogenic substances, PAHs, smokers may end up smoking more cigarettes to satisfy the addictive demand of nicotine receptors. Therefore, it is desirable to develop advanced materials with specific adsorption behavior and high selectivity for future research. Ideally, the desired materials would adsorb a small amount of nicotine or even zero uptakes in cigarette smoke while having high specificity and strong recognition and adsorption for carcinogenic PAHs. In summary, researchers will continue to explore and develop advanced materials with large adsorption capacities, excellent selectivities, and low costs to minimize the harmful effects of cigarette smoke on human health.The authors declare no conflict of interest."
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