Cardiovascular diseases (CVDs) are the number one cause of death, and there is evidence that work exposures could be associated with their development. This study aimed to systematically review observational studies of adults exposed to job strain, effort–reward imbalance, long working hours, job insecurity, shift work, and occupational noise, and assess the association of those work exposures with CVDs.The Navigation Guide framework was applied. The population were adults of working age (18–65), and cohort and case–control studies were included. The work exposures were job strain, effort–reward imbalance, long working hours, job insecurity, shift work, and occupational noise. The outcomes were cerebrovascular diseases, ischaemic heart disease, and hypertensive diseases. The selection, data extraction, risk of bias assessment, and quality assessment were carried out by two reviewers independently and disagreements were solved by a third reviewer or by consensus. The synthesis of the results was done by applying the ‘vote counting based on direction’ method, and the results were summarized in an effect direction plot. The strength of the evidence for every risk factor and CVD was defined by consensus.A total of 17 643 papers were initially identified in the literature search, but after applying the filters by title and abstract, and full text, 86 studies were finally included. From the included studies, sufficient evidence was found of the harmfulness of job strain for cerebrovascular disease and ischemic heart disease. Furthermore, there was sufficient evidence of the harmfulness of shift work for ischemic heart disease. Evidence of no relationship was found between long working hours and shift work with ischaemic heart disease and hypertensive disease, respectively. The other associations of work exposures and CVDs had limited or inadequate evidence of harmfulness.In this comprehensive review, there was sufficient evidence of a harmful relationship between job strain, shift work, and CVDs. For the other work exposures, more high-quality studies are needed. In order to improve current prevention strategies for CVDs, the findings of this review imply that job strain and shift work are work exposures that constitute additional risk factors that could be approached as targets for worksite interventions.PROSPERO CRD42020179972. Although there are many studies on the effects of work exposures on cardiovascular diseases (CVDs), their association is still debated. This systematic review explores the association between six work exposures and three groups of CVDs described in 86 cohort and case–control studies using novel systematic review methods. This review provides identified job strain and shift work as targets for worksite interventions to prevent CVDs.Cardiovascular diseases (CVDs), defined by the World Health Organization (WHO) as a ‘group of disorders of the heart and blood vessels’, are the number one cause of death globally, representing 32% of all global deaths in 2019 . This hiSeveral lifestyle behaviours are associated with the development and clinical manifestation of CVDs . HoweverThe global population has experienced rapid economic growth that has resulted in a variety of occupational exposures that pose a risk for health . During Previous research has shown associations between working conditions and risk of CVDs . One of To understand the relationship between work stress and CVDs, researchers have expanded the concept of work stress beyond the characteristics of the work task to encompass organizational factors, generating conceptual models/approaches that indicate risk conditions where those factors interact . There aAccording to Karasek’s model , ‘job stIn Siegrist’s model , the misIt is recognized that long working hours represent a danger to the health of workers and their families , includiThere is evidence that job insecurity is associated with the incidence of CVDs .Shift work, defined as ‘work occurring outside typical daytime working hours’, is associated with an increased risk of diseases , b.There is evidence that suggests that occupational noise impacts morbidity and mortality from CVDs  under the registration number CRD42020179972.The study question was specified using the Population, Exposure, Comparators and Outcomes (PECO) framework . A summaQuantitative observational research studies, specifically cohort studies and case–control studies, were included.Cross-sectional studies, randomized controlled trials, quasi-experimental trials, cross-over controlled trials, controlled trials without randomization, single-case studies, review articles, short communications, letters with insufficient information to analyse the results, guidelines, dissertations, qualitative studies, scientific conference abstracts, and studies on animals were excluded.Inclusion: Studies of adults of working age at the baseline (18–65 years), working in the formal economy.Exclusion: Studies of children (aged <18 years), unpaid domestic workers, individuals with previous CVDs.No restrictions were imposed on the setting of recruitment.The work exposures that have been included are job strain, ERI, long working hours, job insecurity, shift work, and occupational noise.Studies were included if they applied descriptions of the work risk factors according to the definitions and measures in Unexposed group.Annals of Occupational Hygiene online), which follows the International Classification of Diseases, 11th Revision, 2019 (ICD11) and its equivalence in the 10th Revision (ICD10), within the following groups of diseases: cerebrovascular diseases, ischaemic heart disease, and hypertensive diseases.Development of CVD according to the definitions in CVDs with strong congenital evidence and diseases secondary to others were excluded. Diseases of intracranial, extracranial, and coronary arteries have been excluded because the focus of this review was placed on their effects, which are included in our list of cerebrovascular diseases and ischaemic heart diseases.For eligibility, only studies that measured CVDs with medical records were included. Self-report measures were not considered to avoid bias. Specifically for hypertension, the criteria included only studies where the diagnosis was done after two or more measures on different days to avoid confusion between hypertensive disease and ambulatory hypertension.Following the Navigation Guide recommendations, the first author conducted comprehensive literature searches using electronic academic databases for potentially relevant records from published and unpublished studies.Annals of Occupational Hygiene online]: Search Strategy in Ovid Embase as an example).For published studies, the following electronic academic databases were used: Ovid Embase (1947 to 26 May 2020), Ovid Medline (1946 to 26 May 2020), PubMed (1946 to 26 May 2020), Scopus (1788 to 26 May 2020), Web of Science (1900 to 26 May 2020), and Ovid APA PsycInfo (1806 to 26 May 2020) (see http://www.opengrey.eu/), Open Thesis (http://www.openthesis.org), Grey Literature Report (http://greylit.org/), and ProQuest Dissertations & Theses Global™ (www.proquest.co.uk/products_pq/descriptions/pqdt.shtml).For unpublished studies, these electronic gray literature databases were used: OpenGrey , which was designed and piloted by the reviewers on 10 references before the data extraction.Data were extracted by two reviewers independently and any discrepancies were resolved by consensus or by a third reviewer. The extraction was completed using a data extraction form (see To draw conclusions about the association (harmfulness) of the work exposures and the CVDs assessed, the steps represented in Annals of Occupational Hygiene online]: Instructions for Making Risk of Bias Determinations), which judges the risk of bias by nine domains: recruitment strategy, blinding, exposure assessment, outcome assessment, confounding , incomplete outcome data, selective outcome reporting, conflict of interest, and other sources of bias.The risk of bias of each study was assessed by two reviewers working in parallel by applying an adaptation of the Navigation Guide tool  was used, which assigns a ‘moderate’ quality rating to observational studies and downgrades or upgrades the quality considering eight categories: quality of study limitations , indirectness of evidence, inconsistency of evidence, imprecision of evidence, publication bias, large magnitude of effect, dose–response, and confounding minimizes the effect.For grading the quality of evidence of each outcome by risk factor, the Navigation Guide tool   was used to calculate the one-tailed P-value for each outcome domain (The number of studies (votes) showing harm were compared with the number showing benefit using a sign test excluding those with no effect or conflicting findings . The rese domain . Studiese domain .Finally, the overall strength of the body of evidence of each outcome by working condition and risk factor was rated based on four considerations following the Navigation Guide criteria: quality of body of evidence, direction of effect, confidence in effect, and other compelling attributes of the data that may influence certainty.Annals of Occupational Hygiene online): Instructions for Grading the Quality and Strength of Evidence. The strength of the evidence was rated in one of the following four categories: sufficient evidence of harmfulness, limited evidence of harmfulness, inadequate evidence of harmfulness, and evidence of lack of harmfulness.The final decision about the strength of the evidence was done by the reviewers by consensus by applying the definitions in Although the statistical significance of the results of the individual studies was not considered for the effect direction plot, this information was an input for the final decisions.A total of 17 643 papers were identified in the literature search, 4064 duplicated records were detected and removed by Covidence and manually, leaving 13 579. After reading the titles and abstracts, 393 studies were selected for full-text screening. Of those, 86 studies were included see .The included 86 studies were published between 1982 and 2020. Studies from North America, Europe, and Asia were included; no studies from Africa, South America, or Australia passed the filters. Of the 86 studies, 22 were case–control and 64 were cohort studies.For the analysis, studies were separated and grouped by exposures and CVD outcome. Studies with more than one exposure or/and more than one CVD (outcome) were counted again in their respective groups, raising the number of studies in every group by exposure and CVD from 86 to 114.Distribution of studies by risk factor:•ERI: 6 studies•Job insecurity: 8 studies•Job strain: 40 studies•Long working hours: 17 studies•Occupational noise: 7 studies•Shift work: 36 studiesDistribution of studies by outcome:•Cerebrovascular disease: 21 studies•Hypertensive disease: 22 studies•Ischaemic heart disease: 71 studiesIn the Effect Direction Plot, papers with a high and probably high risk of bias were excluded, incorporating 75 of the 114 studies .For the association of ERI and cerebrovascular diseases, one case–control study with a low risk of bias was included . The oveAnnals of Occupational Hygiene online]: Data Summary). The overall quality of evidence was moderate. The strength of the evidence of harmfulness was limited  and therefore the strength of the evidence was ‘inadequate evidence of harmfulness’ . The overall quality of the evidence was high because all the important confounders were considered in most of the studies, and they showed similar results for the same exposure. The strength of the evidence was ‘limited evidence of harmfulness’ , but the confidence in the relationship is constrained by chance due to the reduced number of studies (for a significant sign test result)  .Annals of Occupational Hygiene online]: Data Summary). The overall quality of the evidence was upgraded as ‘high quality’, due to the consistency in the results across the studies. The strength of the evidence was defined as ‘sufficient evidence of harmfulness’    with higAnnals of Occupational Hygiene online]: Data Summary). The overall quality of the evidence was downgraded to ‘low quality’ due to the individual risk of bias of two of the studies included. The strength of the evidence was rated as ‘inadequate evidence of harmfulness’ . The overall quality of the evidence was upgraded to ‘high quality’ because 59% of studies considered all the important confounders and 90% of the studies considered at least one important confounder. The final decision for the strength of the evidence was ‘sufficient evidence of harmfulness’   , with hiAnnals of Occupational Hygiene online]: Data Summary). The overall quality of the evidence was downgraded to ‘low quality’ due to the individual risk of bias of the studies and the inconsistency in the results across the studies. The final decision of the strength of the evidence was ‘inadequate evidence of harmfulness’ , the reason why the overall quality of the evidence was downgraded to ‘low quality’. The strength of the evidence was ‘inadequate evidence of harmfulness’ . The quality of the evidence was moderate, and the final decision of the strength of the evidence was ‘evidence of lack of harmfulness’ , and therefore the quality of the evidence was downgraded to ‘low’. The strength of the evidence was decided as ‘inadequate evidence of harmfulness’, because of the limited number of studies and the low quality of the evidence.Just one cohort study with a probably high risk of bias was included for occupational noise and cerebrovascular disease . The overall quality was rated as ‘low’. The strength of the evidence was valued as ‘limited evidence of harmfulness’ , the reason why the overall quality of the evidence was downgraded to ‘low quality’. The strength of the evidence was defined as ‘limited evidence of harmfulness’ . The overall quality of the evidence was upgraded to high quality because the studies reported similar results for the same exposure and most of them considered the important confounders. The strength of the evidence was rated as ‘limited evidence of harmfulness’ . The overall quality of the evidence was moderate. The strength was rated as ‘evidence of lack of harmfulness’ . The overall quality was upgraded to ‘high’ because most of the studies (56%) included all the important confounders. The final decision on the strength of the evidence was ‘sufficient evidence of harmfulness’   .In this review, 86 relevant observational studies were identified. Sufficient evidence of harmfulness was found between job strain and cerebrovascular disease, job strain and ischaemic heart disease, and shift work and ischemic heart disease. In contrast, no evidence of a harmful relationship was observed between long working hours and shift work with ischaemic heart disease and hypertensive disease, respectively. These groups of exposures and CVDs include results from well-designed, well-conducted studies. The other associations of this review were classified with limited or inadequate evidence of harmfulness , which ma priori a ‘moderate’ quality rating to the body of human observational evidence, which differs from other methodologies for systematic reviews in the clinical sciences, such as GRADE, which assign them a priori a ‘low’ quality (For the general structure of this systematic review, we applied the Navigation Guide framework. This methodology is a novel alternative for systematic reviews in occupational and environmental health where randomized controlled trials of potentially harmful exposures are not possible. The Navigation Guide assigns  quality . This reDue to the clinical and methodological diversity, and the different effect measures of the studies, for data synthesis, we applied the vote counting method and an effect direction plot, following the latest recommendations of Cochrane . HoweverIn accordance with our results, other reviews applying meta-analysis found significant associations between job strain and CVDs  e.g. ov. In a syWhile governments are primarily responsible for public health policies, employers have a direct responsibility to provide a safe and hazard-free environment for workers (Regarding CVDs, current strategies mainly focused on controlling the cardiovascular factors by individuals’ health care providers have not been enough to reduce the rising prevalence of these diseases (Our results concur with previous reviews, but our findings were corroborated by applying an approach specifically created for systematic reviews of environmental and work exposures, and by presenting results of varied studies in a way other than a narrative synthesis. Though there are several studies about work exposures and CVDs, our findings from multiple exposures also confirmed that more high-quality evidence is needed.wxac004_suppl_Supplementary_File_1Click here for additional data file.wxac004_suppl_Supplementary_File_2Click here for additional data file.wxac004_suppl_Supplementary_File_3Click here for additional data file.wxac004_suppl_Supplementary_File_4Click here for additional data file.wxac004_suppl_Supplementary_File_5Click here for additional data file.wxac004_suppl_Supplementary_File_6Click here for additional data file.


The liver partakes as a sensor and effector of peripheral metabolic changes and a regulator of systemic blood and nutrient circulation. As such, abnormalities arising from liver dysfunction can influence the brain in multiple ways, owing to direct and indirect bilateral communication between the liver and the brain. Interestingly, altered bile acid composition resulting from perturbed liver cholesterol metabolism influences systemic inflammatory responses, blood-brain barrier permeability, and neuron synaptic functions. Furthermore, bile acids produced by specific bacterial species may provide a causal link between dysregulated gut flora and neurodegenerative disease pathology through the gut-brain axis. This review will cover the role of bile acids—an often-overlooked category of active metabolites—in the development of neurological disorders associated with neurodegeneration. Further studies into bile acid signaling in the brain may provide insights into novel treatments against neurological disorders. The liver is the largest internal solid organ in the human body with responsibility for various vital roles, such as macronutrient metabolism and homeostasis , regulatDue to the potential impact of the liver filtrates and products on multiple organ systems , conditiBile acids are physiological detergent-like amphipathic agents synthesized from cholesterol through a complex biosynthesis process managed by 17 enzymes of Cytochrome P450s (CYPs) in the liver hepatocytes . AlthougThe alternative pathway synthesizes the remaining 10% of BAs, which consists predominantly of CDCA . In the Before the excretion of primary BAs from the liver, conjugation with either taurine or glycine occurs in hepatocytes. These conjugated BAs are also referred to as bile salts and possess increased water solubility and lower cytotoxicity for subsequent function in the intestines . CA and Clostridiaceae  in the ileum enterocytes  into systemic circulation via the ATP-binding cassette transporter 1 (ABCA1)  . The ste (ABCA1) .While the gut-specific effects of BA are frequently studied, the role of BA in the nervous system is relatively less understood. Unconjugated and conjugated BAs can enter the CNS through different mechanisms and the amount of BAs in the cerebrospinal fluid correlates to their plasma concentrations . ConjugaRegions of the nervous system situated outside the BBB are particularly susceptible to the effects of BAs. The effects of BAs are prominent in patients suffering from chronic liver conditions, who develop pruritus from the activation of MAS Related GPR Family Member X4 (MRGPRX4) receptor expressed on dorsal root ganglion histamine receptor H1 (HRH1)-positive neurons by BA that have escaped the liver . In normA) receptors, and the N-methyl-D-aspartate (NMDA) receptors  (BAs can further fine-tune energy homeostasis ase (D2) . G protease (D2) . The recase (D2) . As suchase (D2) . Concurrase (D2) , which mase (D2) .Liver dysfunction is often associated with an altered neurological function . In partBacteroides  brain samples presented an enhanced brain-specific CYP27A1 activity with a relatively higher ratio of TCA, DCA, LCA, TDCA, and GDCA . Taurinese model , individcting PD . This iscting PD . Interescting PD  while TUcting PD , suggestcting PD . Despitecting PD , the altcting PD , PD  can independently modulate the function and effects of the brain , gut Zh, and gutSimilarities in BA signaling pathways in both the gastrointestinal tissues and the brain suggest the potential for repurposing BA-related therapeutics for neurodegenerative conditions. Treatment of general health ailments with BA and its constituents has been a long-standing tradition in traditional Chinese medicine . There hTechnical limitations significantly slowed the progress of bile acid and gut microbiome research. Detection of BA content in biological samples through commonly adopted enzymatic assays and mass spectrometric methods has restricted resolution toward BAs with closely related structural features and BAs with abundance levels that differ significantly from the majority of the BA species in the sample . SimilarExamination of the unique aliphatic nature of BAs and known BA transporters present on the BBB provides valuable insights and alternative approaches to drug development for neurological conditions. The majority of existing drugs are insufficiently soluble and permeable for sufficient absorption into systemic circulation upon oral administration . BA conjXY, LT, and SJ: conceptualization. XY, LT, WC, D-YL, and SJ: writing—original draft preparation. XY, Y-AL, TW, SJ, and D-YL: writing—review and editing. TW and SJ: supervision and funding acquisition. TW, SJ, and Y-AL: critical revision of the manuscript. All authors read and agreed to the published version of the manuscript.


Vaccinium macrocarpon) are traditionally used in prevention of urinary tract infections (UTIs). The authors' aim was to evaluate effects of a supplement containing cranberry extract, pumpkin seed extract, vitamin C, and vitamin B2 on recurrent uncomplicated UTIs in women and their intestinal microbiota.Cranberries , intestinal microbiota (assessed by 16S rRNA amplicon sequencing), and evaluation questions. Parameters were assessed at baseline and after 1, 2, and 7 months (start of intake of cranberry supplement after 1 month for 6 months). p < 0.001). Number of antibiotic therapies was also significantly (p < 0.001) reduced by 68% during 6 months of cranberry intake (0.14 ± 0.35) when compared with 6 months retrospectively (1.14 ± 0.71). The SF-36 physical component score increased from 44.9 ± 5.5 at baseline to 45.7 ± 4.6 at 7 months (p = 0.16). The SF-36 mental component score decreased slightly from the baseline value of 46.5 ± 6.5 to 46.2 ± 6.4 at 7 months (p = 0.74). No significant intragroup mean changes at genus, family, or species level for α and β diversity within the intestinal microbiota were found. In the evaluation questions, participants rated the cranberry extract positively and considered it beneficial. The supplement intake was safe.Twenty-three women (aged 52.7 ± 12.4 years) were included in the study. Participants reported 2.2 ± 0.8 UTIs (at baseline) in the previous 6 months. After 6 months of cranberry intake, participants reported a significant decrease to 0.5 ± 0.9 UTIs (This study shows that women with recurrent uncomplicated UTIs benefit from cranberry intake. Future larger clinical studies with further investigation of the mechanisms of action are required to determine the effects of cranberries on participants with uncomplicated UTIs. The costs of managing acute UTIs range from $390 to $730 in the United States according to a recent analysis.2 The present recommendations for treatment of recurrent UTIs consist mainly of elevated intake of fluids, a combination of lifestyle measures, and the use of antibiotics.1 Unfortunately, antibiotic use exerts a negative impact on the gut microbiota, thereby possibly enhancing chronification of UTIs.3Recurrent, uncomplicated urinary tract infections (UTIs) are a frequent clinical problem not only in younger women but also in postmenopausal women with chronic diseases.Vaccinium macrocarpon) are traditionally used in the prevention of UTIs. Several randomized placebo-controlled trials demonstrated a preventive effect of cranberry extracts or cranberry juice on the rate of recurrent UTIs, for example, in younger women.4 However, a Cochrane meta-analysis from 2012 with 24 studies and over 4000 participants concluded that there is no clear evidence that cranberry supplementation may decrease the number of symptomatic UTIs for women with recurrent UTIs.5Extracts from cranberries  is at the forefront. However, the primary mode of action and the compounds responsible for this effect are hitherto unknown. Flavones from cranberries may contribute to the antiadhesive activity.9 Recent metabolomic studies revealed that cranberry juice consumption significantly altered the urinary metabolome and increased urinary excretion of both exogenous and endogenous metabolites.9Among the discussed mechanisms of action of cranberry extracts in UTIs, a putative antiadhesive effect against uropathogenic 10 At least 36-mg cranberry proanthocyanidin (PAC) equivalents per day, divided into two doses (morning and evening), are required to mediate the observed antiadhesion bioactivity considered necessary to prevent bacterial adhesion to uroepithelial cells lining the bladder wall.11 Furthermore, it is most likely that polyphenols, flavonoids, and anthocyanins of cranberries have effects on the gut microbiota. In recent years, the involvement of intestinal microbiota has come into focus as a possible origin of recurrent UTIs.8Inhibition of adhesion of UPEC by cranberry extract and its metabolites was demonstrated in a recent randomized controlled trial.1 Its natural reservoir is the gut. From here, Escherichia coli can colonize the perineal area and the vagina and subsequently infect the urinary tract.1 Antibiotics have been widely used for the treatment of UTIs. However, due to the overuse of antibiotics, increasing resistance has been reported, thus reducing their efficacy and increasing the rate of recurrence.12 Furthermore, antibiotics have a detrimental impact on the gut microbiota, which has been shown to be an essential component of human health.14 It is known that a balanced intestinal microbiota provides colonization resistance to a number of pathogens.15UPEC is responsible for the majority of UTIs (>65%).The aim of this study was to evaluate clinical effects of a cranberry supplement in women with recurrent uncomplicated UTIs and to assess changes in the intestinal microbiome.Women with recurrent uncomplicated UTIs were enrolled in a prospective, uncontrolled exploratory study over 7 months. The study started with a baseline visit (V0), which included a retrospective history taking of the number of UTIs and of the number of antibiotic therapies in the previous 6 months. It was followed by a prospective 1-month run-in phase. Study visits took place after 1 (V1), 2 (V2), and 7 (V3) months .clinicaltrials.gov (NCT03019874).The cranberry supplement was taken for 6 months from V1 to V3. At V0, V2, and V3, fecal samples were collected for the analysis of intestinal microbiota. The study protocol was approved by the ethics committee of the Charité—Universitätsmedizin Berlin, Berlin, Germany (EA1/268/16), and all participants gave their informed consent. Trial registration was done at Individuals with uncomplicated, chronic recurrent UTIs and aged 18 to 70 years were eligible to participate. Chronic recurrent urinary infections were defined as ≥3 infections per year or 2 infections in the last 6 months. Participants were excluded if they had renal insufficiency (glomerular filtration rate <60), any anatomical or known structural causes of UTIs, a regular consumption of probiotics or probiotic yogurt (at least 5 × per week), any intake of antibiotics in the past 4 weeks, any intake of phenprocoumon (or derivatives), or simultaneous participation in another study.The primary outcome was the change in the number of UTIs after the 6-month intake of the cranberry supplement  in comparison with the 6-month retrospective period assessed at V0. Therefore, UTIs were ascertained by a study physician at every study visit. Originally we planned the Acute Cystitis Symptom Score (ACSS) as the primary outcome. However, after inadequate adherence to this questionnaire, the clinical evaluation of UTIs by the physician was defined as the primary endpoint.16Secondary outcomes included change in the number of antibiotic therapies following the 6-month consumption of cranberry supplements  in comparison with the 6-month retrospective period assessed at V0. Antibiotics were ascertained by a study physician at every study visit. Quality of life was measured at V0, V1, V2, and V3 by the German version of the Medical Outcomes Study 36-Item Short-Form Questionnaire (SF-36).17 Further analysis included responders (defined as no UTIs between V2 and V3 during cranberry intake) and self-reported compliance (defined as compliant to the recommended application—3 × 1 capsule daily).At V0, V2, and V3, fecal samples were collected. Analysis of the microbiota was performed by the Institute of Microecology , as described elsewhere.Moreover, expectation (at baseline) and evaluation questions (at V3) were asked using a numeric rating scale .2). The recommended application is 3 × 1 capsule daily. The nutrients supplied in this dosage are in the nutritional–physiological range. The blend was composed in a holistic approach to maintain a healthy bladder.The used cranberry product, named Cystorenal Cranberry plus, is a food supplement. The product has been notified to the Federal Office of Consumer Protection and Food Safety in accordance with the “§5 Food Supplements Ordinance” (German: Nahrungsergänzungsmittelverordnung). One capsule of Cystorenal Cranberry plus contains 300 mg of cranberry extract (including 12 mg of PACs), 100 mg of pumpkin seed extract, 20 mg of vitamin C, and 0.47 mg of riboflavin . The primary endpoint was calculated with the Wilcoxon signed-rank test. UTI frequencies were compared with Fisher's exact test for count data. The secondary endpoint (SF-36) was compared using the Friedman test, and p-values were corrected using a false discovery rate correction for multiple testing. Statistical analysis was based on intention-to-treat analysis. Missing data were imputed with the Multivariate Imputation by Chained Equations package.Statistical analyses resulting in Q ≥ 25. Minimum and maximum sequence lengths with the QIIME default of 200 and 1000 bp were used. The sequences of four independent runs were merged in a single data set. Chimeras were removed using vsearch. Operational taxonomic units (OTUs) were chosen within 97% sequence identity. SILVA ribosomal RNA database release 128 was used to assign taxonomy and align sequences. Following removal of chloroplast and mitochondrial OTUs, further statistical analyses were done with R, version 3.5.4.Sequence data were processed using Quantitative Insights Into Microbial Ecology (QIIME) 1.9.1.76. Quality cutoffs were performed using the QIIME standard at p-Values were calculated with the pairwise Wilcoxon signed-rank test for α diversity and permutational multivariate analysis of variance for β diversity with the package, vegan (dissimilarity index: Bray–Curtis), version 2.5.The vegan package, version 2.5, was used for rarefaction to even sequence depth and exclusion of taxa present in less than 10% of all samples. Alpha diversity indices for observed Chao1 and Shannon as well as β diversity indices such as Bray–Curtis were calculated with the phyloseq package (version 1.30). p-Values were calculated using the difflsmeans function with the R package, lmertest.Relative abundance values were transformed using the centered log-ratio transformation with the R package compositions. The authors then performed a statistical analysis of the differences in microbiota composition between time points for each taxon, by fitting linear mixed models with lmer, considering repeated sampling of individuals as random effects. Sixty-four women were screened for eligibility. Twenty-three women (aged 52.7 ± 12.4 years) were included in the study . ParticiParticipants reported 2.2 ± 0.8 UTIs (at baseline) in the previous 6 months. Impairment of quality of life due to UTIs was moderate on average . Expectap < 0.001) (Participants reported 2.2 ± 0.8 UTIs (at baseline) for the previous 6 months. After 6 months of cranberry supplement intake, the participants reported 0.5 ± 0.9 UTIs, a significant decrease (< 0.001) .p < 0.001) reduced after 6 months of cranberry supplement intake (0.14 ± 0.35 antibiotics) in comparison with the 6-month retrospective period assessed at baseline (1.14 ± 0.71 antibiotic intake). A reduction of 68% was achieved.The number of antibiotic therapies was significantly (p = 0.16). The SF-36 mental component score decreased slightly from V0 (46.5 ± 6.5) to V3 (46.2 ± 6.4) (p = 0.74). See The SF-36 physical component score increased from V0 (44.9 ± 5.5) to V3 (45.7 ± 4.6) . Thus, because of high individual sample variance, a compositional change of the microbiota during the course of the interventions cannot be identified.No significant intragroup mean changes for α and β diversity in the intestinal microbiome were found when testing genus, family, or species level. Relative abundance values using the Bray–Curtis distance matrix were observed in the plot for the analysis of multivariate homogeneity of group dispersion. However, no clustering of time points was identified . As depiBacteroidetes–Firmicutes ratio was observed (p = 0.075) weighted unifrac distances also revealed no effect on β diversity when only comparing repeated measures  were responders (defined as no UTIs between V1 and V3 during cranberry intake) and 14 participants (60.9%) were compliant (defined as compliant to the recommended application—3 × 1 capsule daily). To inspect compositional influences of compliant responders, an ordination plot is shown in None of the models indicated significant effects on repeated measures after adjustment. Analysis of responder versus nonresponder did not reveal any consistent change from baseline according to the classes. The variance reflects the intraindividual variance and does not represent a time effect on the microbiota . One serious adverse event not related to cranberry intake occurred .Overall, cranberry intake was safe. Only mild, self-limiting adverse events occurred, which were not related to cranberry intake  and decreasing the abundance of potential harmful bacteria .25 Two studies used whole cranberry fruit powder made from freshly harvested cranberries,25 while a third used sweetened dried cranberries.26Moreover, cranberry consumption partially reversed the change of gut microbiota in colitic mice by increasing the abundance of potential beneficial bacteria . The PACs from cranberries contain unusual double A-type linkages, which could be important structural features in the antiadhesion process.33 It has been shown that adhesion prevention is equally effective against both antibiotic-sensitive and antibiotic-resistant strains of E. coli34 and that adhesion prevention does not exert selective pressure that can lead to development of resistance.3511 Kinetic data showed that the activity is highest at 36 and 72 mg after 6 h, but decreases significantly after 24 h, suggesting that it may be beneficial to consume more PACs than in this study.11 At 72 mg of PACs , the various metabolites of PACs  are still present and effective 24 h after cranberry consumption.11Dosages of at least 36 mg of PACs per day have been shown to have antiadhesive effects in urine. Increased dosages of 72 mg per day may provide an even longer protection.36 and in another study, no clinical effects were found at even higher PAC levels.37 The mechanism of action of cranberry extract is not yet fully understood. Presumably, synergistic effects, including the presence of soluble oligosaccharides of plant origin in urine, could be beneficial for urinary tract health through both prebiotic effects on the urinary microbiota and direct biological and chemical effects.8However, the importance of the influence of PACs is controversial as PAC-free extracts may also exert antiadhesive effects,A limitation of this study is the uncontrolled study design without placebo control, thus unspecific effects cannot be excluded. Furthermore, the small number of participants precludes a robust statistical analysis. However, this study was designed for exploratory purposes only. In addition, compliance was self-reported only. The overall compliance was moderate, which could be due to the frequent intake of 3 × 1 capsule daily.39 current evidence suggests that the urogenital microbiota play a major role in the occurrence and progression of UTIs.40–42 Hence, additional studies are needed to further clarify the complex host–microbiota interactions for progression of UTIs and the possible influence in relation to cranberry extracts.44Nevertheless, this study showed interesting results and as demonstrated for the intestinal microbiota,In conclusion, this explorative study showed evidence that women with recurrent uncomplicated UTIs can benefit from cranberry intake regarding reduction of numbers of UTIs and antibiotic therapies. Cranberry intake was well accepted by the participants and considered safe. The authors could not observe any changes in α and β diversity of the intestinal microbiota.To better evaluate the impact of cranberries on recurrent uncomplicated UTIs, well-designed double-blind trials are needed, which include longer-term follow-ups, larger sample sizes, and further study of the mechanisms of action. It is therefore necessary to further investigate the possible effects of cranberry oligosaccharides and other complex carbohydrates on the gut and urinary tract microbiota and their health benefits.


White spot lesions (WSLs) are prevalent and often lead to aesthetic problems and progressive caries. The objectives of this study were to: (1) develop a novel resin infiltrant containing smart monomer dodecylmethylaminoethyl methacrylate (DMAEM) to inhibit WSLs, and (2) investigate the effects of DMAEM incorporation on cytotoxicity, mechanical properties, biofilm-inhibition and protection of enamel hardness for the first time.DMAEM was synthesized using 1-bromododecane, 2-methylamino ethanol and methylmethacrylate. DMAEM with mass fractions of 0%, 1.25%, 2.5% and 5% were incorporated into a resin infiltant containing BisGMA and TEGDMA. Cytotoxicity, mechanical properties and antibacterial effects were tested. After resin infiltration, bovine enamel was demineralized with saliva biofilm acids, and enamel hardness was measured.p > 0.05). Biofilm metabolic activity was reduced by 90%, and biofilm lactic acid production was reduced by 92%, via DMAEM (p < 0.05). Mutans streptococci biofilm CFU was reduced by 3 logs (p < 0.05). When demineralized in acid and then under biofilms, the infiltrant + 5% DMAEM group produced an enamel hardness  of 2.90 ± 0.06 GPa, much higher than 0.85 ± 0.12 GPa of the infiltrant + 0% DMAEM group (p < 0.05).DMAEM infiltration did not increase the cytotoxicity or compromise the physical properties when DMAEM mass fraction was below 5% (A novel resin infiltrant with excellent mechanical properties, biocompability, strong antibacterial activity and anti-demineralization effect was developed using DMAEM for the first time. The DMAEM resin infiltrant is promising for inhibiting WSLs, arresting early caries, and protecting enamel hardness. Dental caries is one of the most prevalent oral diseases globally . White sIn the oral cavity, dental caries starts with the breakdown of the dynamic balance of oral microecology . During Streptococcus mutans UA159 (S. mutans), Streptococcus gordonii DL1 (S. gordonii), and Streptococcus sanguinis SK1 (S. sanguinis) under different pH were tested by serial microdilution assays  develop a novel intelligent resin infiltrant containing smart monomer dodecylmethylaminoethyl methacrylate (DMAEM) to inhibit WSLs, and (2) evaluate the cytotoxicity, mechanical properties, biofilm-inhibition and protection of enamel hardness of the novel resin infiltrant. The following hypotheses were tested: (1) Novel resin infiltrant containing DMAEM could be successfully synthesized; (2) DMAEM resin infiltrant could inhibit biofilm growth and acid production; and (3) DMAEM resin infiltration could protect enamel and retain its hardness after biofilm acid attacks.2SO4 and vacuumized. Then 31.8 mL methylmethacrylate, catalyst CAA  and polymerization inhibitor methoxyphenol  were added at room temperature. After stirring at 100-110°C for 12 h, CAA  was supplementary, and then stirred for another 12 h, cooled to room temperature and evaporated.According to the work described previously, DMAEM was synthesized and verified . In brieAccording to the study published before, the experimental resin infiltrant contains bisphenol-Adiglycidyl methacrylate , triethylene glycol dimethacrylate , and a light cure initiator system based on camphorquinone (CQ) and ethyl 4-N,N-dimethylaminobenzoate (4E) . DMAEM w2  was used as a mold for the samples . 5 μL of2 . The negRectangular molds (2 × 2 × 25 mm) were used for mechanical testing . After cSaliva derived biofilm was used in the study. Ten healthy individuals without active caries with natural dentition served as donors. Donors did not take any antibiotics in the three months previous to donation and fasted for two hours. The saliva was diluted two-fold with sterile 50% glycerol. Then the saliva was stored at -80 °C .2 with 37 °C. The medium was refreshed every 12 h. After 24 h, phosphate-buffered saline (PBS) was used to rinse the biofilms to remove loose bacteria.Each well of 96-well plate with resin infiltrant was added with 300μL Mcbain medium . The salA crystal violet assay was performed to analyze biomass accumulation . BrieflyThe biomass accumulation reflects the whole biofilm which contains live cells and dead cells. It is important to evaluate the metabolic activity that was produced by live cells only. In the present study, the MTT -2,5-diphenyltetrazolium bromide) assay was used to measure metabolic activity . Each gr2 with 37°C for 3 h to produce acid. After 3 h, the BPW solution was used for lactate analysis. An enzymatic (lactate dehydrogenase) method was used to evaluate the lactate concentrations. Microplate reader was used to measure the absorbance at 340 nm for the collected BPW solutions. Standard curves were prepared using a lactic acid standard .First, biofilms were rinsed by cysteine peptone water (CPW) to remove loose bacteria . And 300BacLight Live/Dead Bacterial Viability Kit  was used in the study . Live bastreptococci. Third, MSA agar culture plates plus 0.2 units of bacitracin per mL were used to determine the number of mutant streptococci  analysis . Three tptococci .For anti-demineralization test, bovine teeth were used as previously described . In brie2, 8.7 mM KH2PO4, and 0.05 ppm NaF 2, KH2PO4, NaF; Biofroxx, Hessen, Germany)  . The bloGermany) Figure 1Enamel hardness was measured before the demineralized treatment, after demineralization in acid solution, after resin infiltration and after demineralization under biofilms. A hardness tester  was employed using a Vickers diamond indenter with a load of 25 g for 5 s dwell time . Six indStatistical analyses were performed with SPSS, version 22.0 . One-way analysis of variance (ANOVA) was performed to detect the significant effects of the variables. Tukey’s multiple comparison test was used to compare the means of each group at a p-value of 0.05.p < 0.05) had acceptable cell viability (p > 0.05).Cell viability results of resin infiltrant are plotted in p > 0.05). The DMAEM modification did not affect the mechanical properties of resin infiltrant.Mechanical properties of resin infiltrant are shown in p < 0.05), while the infiltrant + 1.25% DMAEM group didn’t show significant difference (p > 0.05). Crystal violet assay and lactic acid production assay plotted similar results, with the increase of DMAEM concentration, the biofilm accumulation and the lactic acid production decreased (p < 0.05).p < 0.05). CFU has reduced the total streptococci counts by around 1 log from the infiltrant + 0% DMAEM group (control) to the infiltrant + 1.25% DMAEM group, by more than 2 logs to the infiltrant + 2.5% DMAEM group, and by more than 4 logs to the infiltrant + 5% DMAEM group (p < 0.05). For mutans streptococci counts, the infiltrant + 1.25% DMAEM group reduced around 1 log, the infiltrant + 2.5% DMAEM group reduced around 2 logs, and the infiltrant + 5% DMAEM group reduced more than 3 logs compared to the control group (p < 0.05).CFU is plotted in p < 0.05), and the percent of live bacteria decreased with increasing DMAEM concentration (p < 0.05).Live/dead staining images Figure 6p < 0.05), while the resin infiltration recovered the hardness (p > 0.05) (p < 0.05). After two stages of demineralization: first in acid solution, second in biofilm culture, the enamel showed the lowest hardness in all the group (p < 0.05). While the hardness value increased as the increasing of the DMAEM concentration (p < 0.05) . Additionally, the antibacterial effect enhanced the anti-demineralizing properties under the attack of biofilm for 7 days.in vitro cytotoxicity tests, the MTT value is not less than 80% prove to be slightly cytotoxic . In detail, flexural strength of the resin infiltrant was around 120-130 MPa, while the elastic modulus was about 4 GPa, which were similar to other results . Metabolic ability and biofilm accumulation were all reduced significantly with the increase of DMAEM concentration (p < 0.05). Therefore, the new intelligent resin infiltrant containing DMAEM are promising to inhibit biofilm growth. The pH-sensitive ability of DMAEM confers intelligent antibacterial properties to the novel resin infiltrant. DMAEM is a kind of intelligent materials, that could respond to the decrease of pH. In our previous work, DMAEM showed strong antibacterial effects when pH was 5. While when pH was 7.4, the MIC and MBC of DMAEM were more than 13.5, which showed lower antibacterial activity  compared to sound enamel and experimental resin infiltrant containing TEGDMA and BisGMA . Biofilm metabolic activities, biofilm biomass, lactic acid production were substantially reduced, and biofilm CFU was reduced by up to 3 log. After acid attack by acid solution and then under by biofilms, the infiltrant + 5% DMAEM group produced an enamel hardness of 2.90 GPa, much higher than 0.85 GPa of the control infiltrant + 0% DMAEM group. Therefore, the novel intelligent resin infiltrant is highly promising for enamel infiltration to protect tooth structures and inhibit dental caries.Development of novel dental materials that show an antibacterial effect only during microdysbiosis is an ideal way to inhibiting WSLs while maintaining a healthy oral eubiosis. In the present study, a novel pH-sensitive resin infiltrant containing DMAEM was synthesized for the first time. The new resin infiltrant presented good biocompability when the mass fraction of DMAEM was below 5% ; the Research Funding from West China School/Hospital of Stomatology Sichuan University, RCDWJS2021-19 (L.C.); China Postdoctoral Science Foundation Funded Project (519000-X92209); Research Funding from West China School/Hospital of Stomatology Sichuan University (No. RCDWJS2022-2).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.


INAA was chosen for its ability to perform elemental analysis without any preliminary sample treatment that could introduce systematic errors. The distribution of major elements was relatively uniform, with the sampling locations having less influence. Concerning the trace elements, excepting the PCE Cr, Ni, Cu, Zn, As, and Sb, their distributions presented the same remarkable similarity to the Upper Continental Crust (UCC), North American Shale Composite (NASC), Average Bottom Load (ABL), and Average Dobrogea Loess (AVL), and were in good concordance with the location of the Serbian Danube River in the Pannonian Plain. In the case of considered PCE, both Enrichment Factor and Pollution Load Index showed values higher than the pollution threshold, which pointed towards a significant anthropogenic contamination, and rising concern to what extent the water quality and biota could be affected.To determine the nature and origin of the unconsolidated bottom sediments, as well as to demonstrate and quantify the presence of Presumably Contaminating Elements (PCE) in the Serbian Danube River, as a novelty, the mass fractions on nine major elements as oxides—SiO Within it, the Serbian section, which begins at the Serbian–Hungarian border and ends at the confluence with Timoc River at the Serbian–Bulgarian border, has a length of 588 km, i.e., 20.6% of the total river length [The Danube River, with a total length of 2857 km and a catchment basin of 817,000 kmAccording to its geomorphology, the Serbian section can be divided into three units, e.g., the Pannonian Danube between the Serbian–Hungarian border and Golubac, with a length of 391 km; the Iron Gate Danube between Golubac and Kladovo, with a length of 111 km; and the Lover Danube between Kladovo and Serbian-Bulgarian border on Timok River, with a length of 86 km .The Pannonian unit, which flows the Pannonian Basin, presents typical characteristics of a low-gradient fluvial river, such as a sandy riverbed, bifurcating courses with numerous meanders, sand islands, and sandbars. Sedimentary material shows a well-evidenced stratification, which should reflect also the Pannonian Basin geochemistry and mineralogy, the main source of depositional material.The second two units of the Serbian Danube River have significantly changed as a result of the construction of the Iron Gate Hydropower and Navigation System (IGHPNS), comprising two large dams, one at km. 943 and the other downstream at 862.8. These created two reservoirs that extended upstream of the dams by 300 and 80 km, respectively . Both daRegarding sediments, excepting the Danube River at the entrance in Serbia, there are another three important sources of depositional material transported by the Tisa, Sava, and Velika Morava, the main Danube tributaries along Serbian Sector . Given sIndeed, according to , the maiThe origin of depositional material can be attributed, in different proportions, to the bedrock lithology, of which age is known, while the rest of sedimentary material can be considered a mixture of different components, of which exact origin, due to a continuous erosion and deposition, could not be exactly traced back. According to , the bedAnother peculiarity of the investigated sector of the Danube River is related to the presence of human agglomeration centers, such as Novi Sad, with over 365,000 inhabitants [For this reason, in recent decades, the anthropogenic contamination of the Serbian sector of the Danube catchment basin, and especially Danube and Sava River sediments, has been the subjects of an appreciable number of studies ,13,14,15Besides the presence and quantification of PCE, the geochemistry of the Serbian sector of the Danube River has been less investigated, although this aspect is worth attention, taking into account that, according to , at the To fill this gap, 13 samples of unconsolidated superficial sediments were collected along the Serbian sector of the Danube River between Belgrade and Iron Gate 2 dam, including the confluence of Sava, Velika Morava, and Pek tributaries . All samFor a better understanding of sediment geochemistry, we have reported our data to some general systems, such as Upper Continental Crust (UCC) , North AGiven the diversity of depositional material sources, as well as the presence of urban and industrial potential contamination along the Serbian sector of the Danube River and its tributaries, the main goals of this study were:(i) To evidence any similarities or dissimilarities between the geochemistry of Danube River sediments (Serbian Sector) and crustal material, such as UCC  and NASC(ii) To quantify the contribution to environmental contamination of those PCE of which mass fractions were determined by INAA;Therefore, a related achievement of these objectives represents, in our opinion, a new approach, able to understand not only the geochemistry of Danube sediments in relation to their location, but also to evidence to what extent this sector of the Danube river is affected by anthropogenic contamination.The results of our study performed under these circumstances will be further presented and discussed.To accomplish this project, 11 samples of surface sediments (0–15 cm deep) and two samples of deeper sediments  were collected between Belgrade and the Iron Gate 2 dam . The sedhttps://www.fritsch-international.com/ (accessed on 1 September 2022)) at 400 rpm. After that, from each homogenized sample, six aliquots of about 0.1 g were selected and irradiated at the IBR-2 reactor to be independently investigated via INAA.At FLNP, all sample processing and INAA measurements were performed in the Sector of Neutron Activation Analysis and Applied Research (SNAAAR). Here, each sample was again homogenized for 15 min using a PULVERISETTE 6 planetary ball mill ) software and processed using a proprietary software [After irradiation, gamma spectra were recorded using a HPGe detector with a 1.9 keV resolution for the software . This pesoftware , calculaSpecial attention was paid to quality control. This was done by simultaneous use of more Standard Reference Materials (SRM), e.g., 1633c-Coal fly ash, 667-Estuarine sediment, 2710-Montana Soil, and 1547-Peach leaves, as well as 2709-Trace elements in soil, 1632c-Trace elements in coal, 690CC-Calcareous soil, 2709a-San Joaquin soil, and SRM-AGV2–Andesite for short- and long-living isotopes .Furthermore, all of them were reunited by forming the Group of Standard Sample (GSS) proprietary software ,31, withTM (https://www.statistica.com/en/ (accessed on 1 September 2022)) and PAST 4.09 [For a better description and characterization of the experimental data in relation with closer systems, such as UCC , NASC 22, ABL 2, and ADLAST 4.09  softwareThe experimental INAA data, e.g., average mass fractions and CSU  values, The final results concerning the presence of major, rock-forming elements are illustrated using the spider diagram reproduced in Violin diagrams were chosen for major elements as it permits the visualization of the entire distribution function, together with important statistical parameters, while a box-and-whiskers plot was preferred in the case of trace elements. In both cases, all data were normalized to UCC  as one oAs mentioned before, excepting CaO, the average values of the mass fractions of major, rock-forming elements were relatively close to UCC , NASC 2, ABL 2424, and A2, less than 2.5%, suggests an almost uniform origin of sedimentary material from the point of view of siliceous minerals.Silica, which represents the major component of the investigated sediments, presented an average value of 66.86 wt%, almost identical with 66.62 wt% for UCC , and eve2O3 showed an average mass fraction slightly smaller than UCC [2O were shown to be significantly lower than in the case of UCC [2O.At its turn, Althan UCC , NASC [2than UCC , and ABLthan UCC , but higthan UCC . On the e of UCC , NASC [2e of UCC , and ADLe of UCC . Differee of UCC  (Table 22O + K2O vs SiO2 (2O/Al2O3 vs. K2O/Al2O3 (2O − Al2O3 − Na2O + CaO (K-A-CN)  c and SiO2O + CaO d suggest2O + CaO c. It is As shown by the data presented in To detail this analysis, it was necessary to use multiple-sample ANOVA tests. In this regard, the Tukey’s Q test gave a probability equal to one to have the same mean, Kruskal–Wallis gave the same result for medians, and only non-parametric Mann–Whitney and Dunnet post hoc tests  evidenceMoreover, it should be pointed out that the investigated area, with a total length of 175 km (about 6.2% of the Danube River length), entirely passes through the Pannonian Plain. All above mentioned findings confirm previous conclusions, according to which, the investigated materials have, regardless of sampling points, the same geochemistry closer to crustal one.Two variants of INAA, Thermal and Epithermal Neutron Analysis, permitted determination of the mass fractions of at least 29 trace elements, including nine lanthanides, the presence of which was detailed discussed in . TherefoTrace elements are important as their distribution permits inferring the nature of depositional material and, in some instances, the anthropogenic influence manifested by an anomalous increase of the mass fraction of some PCE.Concerning trace elements Sc, Zr, La, Th, and U, their presence has almost never been associated with any anthropogenic contamination ,35, whil2 vs. Ni  [i,jEF represents the EF of the i-th element corresponding to the j sample, i,jc represents the mass fraction of the i-th element corresponding to the j sample, Sc,jc represents the mass fraction of the Sc corresponding to the j sample, i,UCCc represents the mass fraction of the i-th element in the UCC [Sc,UCCc represents the Sc mass fraction in the UCC [Under these circumstances, we have considered the Enrichment Factor (EF) , as one  the UCC , while t the UCC .Sc was chosen as reference element because its presence in not linked to any industrial or human activity.PLI) [EFs:n represents the number of considered PCE for each sample j.To evaluate the global contamination status of the sediments, we have used the Pollution Load Index (PLI) , definedEF ≥ 1, while the sediment could be considered as contaminated if PLI ≥ 1. In both cases, EF and PLI less than one signifies the absence of any anthropogenic contamination. It is worth mentioning that the selection of the UCC as zero contamination reference represents, as mentioned before, a conservative approach. This is not a universal criterion, as in some regions, such as Chaco, Argentina [According to ,44, a PCrgentina ; Hokuetsrgentina ; or the rgentina , the natrgentina  one. DepEF for all sampling points, as well as for the considered PCE, i.e., Cr, Ni, Cu, Zn, As and Sb, are reproduced in EF higher than one, which suggests, especially in the case of Sb, a significant degree of contamination. In addition, it should be remarked that antimony, regardless of whether it is an oxic or anoxic substrate, is partially soluble in water [Final results concerning the distribution of in water . Given iPLIs of sedimentary material collected from all other places were within one standard deviation closer, which, according to [On the other hand, excepting the sampling points 1S (confluence of Sava River with the Danube), 5 (Smederovo), and 6M (confluence of Morava River with Danube), and, to a lesser extent, 9P , the rding to , suggestIn our opinion, the increased degree of local contamination as evidenced for sediments collected at the confluence of Sava River with Danube—1S, Smderovo—5, and at the confluence of Morava River with Danube—6M needs a future detailed investigation in context of presumably local PCE sources.Almost all investigated PCE present a certain degree of solubility in water, mainly as organo-metallic compounds, increasing the necessity for a similar investigation of their presence in the Danube River water. This problem is even more important as the Danube catchment basin, to the Serbia–Bulgarian border, covers six countries, some of them among the most industrialized nations in Europe. Therefore, besides sediment contamination, a systematic investigation of Danube water is necessary to evidence any trans-boundary transport of contaminants ,50,51.The mass fraction distribution of nine major, rock-forming elements, Si, Ti, Al, Fe, Mn, Ca, Mg, Na, and K, as well as another 20 trace elements, i.e., Sc, V, Cr, Co, Ni, Cu, Zn, As, Rb, Sr, Zr, Sb, Cs, Ba, La, Hf, Ta, W, Th, and U, were determined by Instrumental Neutron Activation Analysis in 13 samples of shallow, unconsolidated sediments collected along the Eastern Serbian sector of the Danube River, from Belgrade to Iron Gate II dam.As a reference, the mass fractions of the same elements in Upper Continental Crust (UCC), North American Shale Composite (NASC), Average Bottom Load (ABL), and Average Dobrogea Losse (ADL) were used.The distribution of major elements revealed, on one hand, a relative uniformity of their presence, less influenced by the location of sampling points, and a striking similitude to their distribution in all above-mentioned reference systems on the other. This finding appears in good concordance with the location of the Serbian Danube River in the Pannonian Plain, of which sediments represent a mixture of depositional material of different ages from Neoproterozoic–early Paleozoic to Cenozoic and Quaternary.The distribution of incompatible elements, Sc, Zr, La, Hf, and Th, confirmed the crustal origin of sedimentary material, as well as its homogeneity along the entire Eastern Serbian sector of the Danube River.About 30% of the investigated trace elements could be categorized as Presumably Contaminating Elements as their mass fractions exceeded the UCC by 100% in the case of Cr and Ni, 250% for Cu and As, about 300% for Zn, and a maximum of 850% for Sb. These facts were confirmed by the Enrichment Factor and Pollution Load Index, of which, values were systematically much higher than one unit, the threshold for uncontaminated sedimentary material, suggesting the existence of a significant contamination level of the investigated sector of the Danube River.This last inference increases the necessity for a continuous investigation of the Danube River sediment contamination and especially the monitoring of the Danube River water along its path to the Black Sea to evidence the routes of transboundary contamination. In our opinion, such an investigation should be extended to the aquatic flora and fauna, including sturgeons as key indicators for the quality of aquatic environment.


Scientific evidence to support the development of appropriate policy for electronic cigarette use is limited by rapidly changing technology and a lack of long-term data. Perceptions of risk and benefits determine diverse framings of the e-cigarette debate and complicate policy decisions. E-cigarette use by smokers who are attempting to quit may result in improved health outcomes, while their use among young people and non-smokers may lead to adverse health consequences. The purpose of this study was to identify the types of evidence used during public consultations on proposed revisions to New Zealand’s e-cigarette legislation in 2020.frequently cited evidence to understand how stakeholders and organisations used evidence.Using submissions to parliament made by the tobacco/e-cigarette industry and the health sector, we assessed the cited evidence for quality and independence measured by publication type and tobacco industry connections. We identified themes from a sub-sample of n = 21) and health organisations (n = 36). A total of 442 pieces of evidence were cited at least once. Health organisations were more likely to cite peer-reviewed evidence (OR = 2.99). The industry was more likely to cite evidence outside of peer review and sources with tobacco industry connections (OR = 4.08). In the sample of frequently cited evidence, youth prevalence and flavours were the most common themes. In some cases the same evidence was used by both groups to support opposing policy positions.The sample consisted of 57 submissions from the e-cigarette and tobacco industry (The industry continues to rely more heavily on evidence published outside of the peer-review process, which is, therefore, subjected to less scientific scrutiny. By using a smoking-cessation or harm-reduction narrative, the industry could be seen as a legitimate stakeholder in policy development. Health policies informed by high quality, rigorous, and systematic evidence are more likely to be effective . EvidencThe New Zealand Government stated its intention to regulate e-cigarettes in 2017 . AlthougDuring this period, industry marketing efforts intensified , and e-cAs part of the Bill’s consultation process, the government called for public submissions for consideration by the Health Select Committee. Despite a nationwide COVID-19 lockdown during this period, there was a great deal of interest in the Bill, with over 1,200 written and 84 oral submissions. Our study examines the research evidence cited by selected stakeholders to support policy positions and claims on the proposed regulation of e-cigarettes in New Zealand. Health organisations and industry organisations, including e-cigarette and tobacco companies (hereinafter "the industry"), were considered to have the greatest interest in this policy debate. Health organisations serve populations of interest and have relevant public health and scientific expertise. The industry has considerable financial investments, resources, and e-cigarette product knowledge. Therefore, both groups are well positioned to provide comments on the proposed legislation. Aligned with previous research  we assesWritten submissions on the proposed Bill, made by organisations, were obtained from the New Zealand Parliament website . We idenp = .05) were used to evaluate differences between organisation type and publication type using SPSS 27.All citations included in the sample of submissions were imported into Microsoft Excel 16.47.1. We defined a piece of evidence as a unique work or publication. To assess the quality of the cited evidence, each piece was coded by publication type as outlined in n = 33).To assess potential industry influence, we identified tobacco industry connections for all the extracted publications according to the criteria in n = 19).We determined the most frequently cited sources based on the number of organisations, within each group, that cited each piece at least once. We ranked each source by the number of organisations that cited each piece and included the ten most frequently cited pieces for each group. We then conducted a thematic analysis of the ten most frequently cited sources for each of the two groups . As shown in 2x  = 27.651, p<0.001). Industry lodged submissions cited a significantly lower proportion of peer-reviewed evidence (37%) compared to health organisations (64%). Industry submissions were significantly more likely to cite reports, news articles or other sources. On a per submission basis, health organisations were three times as likely to cite peer-reviewed evidence with an average of 9.6 peer-reviewed sources per submission, compared to 2.1 per industry submission. The industry was more likely to draw upon evidence connected to the tobacco industry (15.5%) compared with 4.3% of health organisations. Eleven of the 18 tobacco industry connected sources presented by industry were peer-reviewed. Of the tobacco industry connected evidence cited by health organisations, the majority  were utilised by one health organisation. The majority of supporting evidence in the industry group was provided by tobacco companies (91%); independent e-cigarette companies cited just 11 of the 116 publications for this group.Four hundred and forty-two pieces of evidence were cited at least once in the total sample of submissions (n = 7), followed by reports (n = 2) and one academic blog. The most frequently cited evidence utilised by industry were reports (n = 6), followed by peer-reviewed publications (n = 3), and the Bill itself. One peer-reviewed journal article  was cited by 14 health organisations and two industry organisations, making it the most cited piece of evidence in the sample. A summary of the most frequently cited sources is provided in The most frequently cited evidence utilised by health organisations were peer-reviewed publications  and flavours (40 citations using 5 pieces of evidence). These themes mapped closely to key policy areas addressed within the proposed Bill. We appraised how both the industry and health organisations utilised these pieces of evidence in their submissions.From the subset of most smoking cessation focus, and supported statements made by organisations that e-cigarette use was supporting a reduction in youth smoking, and/or that e-cigarette use among youth is negligible. The second position aligned with a youth and non-smoker focus and supported claims that youth uptake of e-cigarettes is high, and/or that youth smoking rates are increasing. Our analysis indicates that of the organisations that cited these three documents, the industry aligned with the smoking cessation focus, as did four of the health organisations, while the remaining 14 health organisations that used these sources to support their position aligned with the youth and non-smoker focus , Farsalinos et al. (2013), Gendall et al. (2020), Zare et al. (2018) and Meernik et al. (2019). Two distinct positions were again identified. The first position aligned with the smoking cessation focus, that flavours are important for smoking cessation, and/or any restrictions could have unintended consequences for smokers, e.g., relapse. The second position aligned with the youth and non-smoker focus and supported statements that flavours increase appeal beyond smokers to non-smokers and/or young people and/or that flavours decrease perceptions of harm. Of the organisations to reference any of the frequently cited pieces, the industry (n = 2) aligned with the smoking cessation focus, as did two health organisations and the remaining 11 aligned with the youth and non-smoker focus  presented concerns about e-cigarette use among youth in NZ.Our study reveals that the same pieces of evidence were used to support divergent policy positions. Using the same evidence, but arriving at a different conclusion, is not uncommon within the e-cigarette policy debate , 22. Forfrequently cited evidence are positioned within a smoking cessation focus. For example, one tobacco company stated, “the removal [of e-cigarette flavour options] will likely cause some smokers to relapse” [The industry’s statements in the sub-set of relapse” . This aprelapse” , 26 whilrelapse” . This porelapse” . This marelapse” .While it is expected that stakeholders use evidence that will support their policy preferences, the use of tobacco-industry connected sources is highly problematic. Our study reveals that despite the availability of the latest New Zealand specific evidence on flavours  and two most frequently cited evidence some organisations did not cite these sources but did argue a position on flavours or youth uptake. It should also be noted that this study uses publication type as an indicator for quality of evidence, but findings do not include an in-depth quality assessment for each piece. We acknowledge that standards vary in peer-review [Our study has some limitations. Conflicts of interest are self-defined and operate on a trust-based model where authors declare their interests and funding sources truthfully. However, the enforcement of these conflicts is limited , and ther-review  and otheE-cigarette regulation globally is evolving as jurisdictions seek to adopt regulations for new products. Policy makers look to evidence to inform decisions, yet our study shows that given the emerging and changing nature of e-cigarette evidence, the very same research can be positioned by opposing interests to support both stronger and weaker regulations. Further, the industry utilises more evidence published outside of the peer-review processes, subject to less scrutiny from scientific experts, and evidence linked to the tobacco industry compared to health organisations. The industry prioritises a smoking cessation framing to gain acceptance in the policy process and positions itself as part of the solution to smoking-related disease. Signatories of the WHO FCTC are expected to protect public policy from tobacco industry interference and must treat industry evidence with caution. A process of organising evidence by publication type and independence may benefit policymakers to prioritise higher quality evidence and identify that which may require further scrutiny, particularly publications with tobacco industry connections.S1 File(PDF)Click here for additional data file.


Compared with normal spleen, the concentrations of acetate, alanine, glutamine, glycerol, isoleucine, lysine, valine, phenylalanine, leucine, and methanol in ITP spleen tissue were elevated and 3-hydroxybutyric acid, ascorbate, asparagine, ethanol, glycogen, low-density lipoprotein, malonate, myo-inositol, glycerophosphocholine, pyroglutamate, and taurine were decreased. Amino acids metabolic pathways, such as branched-chain amino acids pathway, were identified as the main involved pathways based on enrichment analysis. The decrease in taurine level in the spleen was the most obvious metabolic signature involving ITP with high sensitivity and specificity to distinguish the spleen of ITP from the normal (CI: 0.825–0.982). Notably, the level of taurine in the spleen was negatively correlated with the efficacy of splenectomy . Collectively, the data from our study revealed previously unknown ITP-related metabolomic changes in the spleen and found a potential diagnostic and efficacy-predictive biomarker for ITP treatment.Idiopathic thrombocytopenic purpura (ITP) is a common hematological disease and the abnormal platelet destruction in the spleen is a critical pathological mechanism for ITP. However, the metabolomic change in the spleen caused by ITP is still unclear. In the present study, the metabolomic information of 18 ITP and 20 normal spleen samples were detected by using  Idiopathic thrombocytopenic purpura (ITP) is a common hematologic disorder characterized by thrombocytopenia. For most patients, bleeding is the most common clinical manifestation. The pathology is very complex, involving diverse abnormal cellular and humoral immunity. The thrombocytopenia in ITP is mainly caused by circulating platelet autoantibody-mediated destruction and production impairing ,2,3,4. M1H high-resolution magic angle spinning NMR spectroscopy, trying to figure out the underlying pathological changes in metabolic level and the corresponding relationship with clinical outcomes.However, some patients do not respond favorably to medical treatments. Since having a predicted 5-year hemorrhage-related mortality ranging from 2.2% to 47.8% across different age groups, refractory patients are candidates for splenectomies . ThroughBased on durative platelet count and bleeding, thirteen, two, and three ITP patients were classified into the complete response (CR), partial response (PR), and no response (NR) groups, respectively. Histological observations of spleen tissues ensured that no spleen sample was contaminated with other primary spleen diseases .1H HR-MAS NMR spectra of ITP and normal spleen tissue were presented in Representative 2X = 0.268, R2Y = 0.782, Q2 = 0.333) from the response permutation test (p = 0.008) indicated non-overfitting and an acceptable reliability and predictability of the model. A total of 21 metabolites were identified as discriminatory metabolites between the ITP and control groups. Compared with the normal spleen, the concentrations of acetate, alanine, glutamine, glycerol, isoleucine, lysine, valine, phenylalanine, leucine, and methanol in ITP spleen tissue were elevated and 3-hydroxybutyric acid, ascorbate, asparagine, ethanol, glycogen, low-density lipoprotein, malonate, myo-inositol, glycerophosphocholine, pyroglutamate, and taurine were decreased  analysis, we found the area under the curve (AUC) of taurine was 0.912 (CI: 0.825–0.982), and the decrease in spleen taurine level has a high sensitivity and specificity to distinguish ITP from the normal A,B. Whenn = 9, respectively) (n = 9) was in remission without needing special treatment, while only 45% of patients in H-tau groups were in remission of thrombocytopenia (p = 0.029). The Spearman correlation analysis indicated the level of taurine is negatively correlated with the response to a splenectomy   C. Duringytopenia . The rat= 0.006) D.Achieving a definitive diagnosis of ITP has long been a challenge for clinicians because the specific pathogenesis of the disease is undetermined. The diagnostic principles for ITP were mainly based on clinical symptoms, platelet counts, and exclusive diagnosis of other secondary diseases . TherefoIn the present study, multiple amino acids were elevated in ITP, including glutamine and branched-chain amino acids (BCAAs). Elevated amino acid levels may relate to the metabolic reprogramming of immune cells in the spleen during their activation, especially macrophages, and meet metabolic and regulatory demands upon activation of immune cells in the spleen of ITP. For immune cells, the utilization of glutamine is linked to functional activities such as cytokine production, nitric oxide production, superoxide production, and phagocytosis. Many immune cells including lymphocytes and macrophages utilize glutamine at a higher rate than glucose in immunological response . Most glBCAAs, including leucine, isoleucine, and valine, are essential amino acids for immune cells which can be incorporated into proteins or oxidized into branched-chain ketoacids (BCKAs) for biosynthesis and further oxidative phosphorylation. Previous reports demonstrated that immune cells have high branched-chain amino acid transaminase (BCAT) and branched chain ketoacid dehydrogenase (BCKD) activity levels and the uptake rate of BCAAs is highly increased, especially in response to mitogens . In addi2−) and nitric oxide (NO) to provide cytoprotection. Prolonged taurine deficiency may lead to significant leukopenia and depletion of cells in the B-cell area of the spleen [In addition to elevated amino acids such as glutamine and BCAAs, we found taurine is significantly decreased in the ITP spleen and, interestingly, the level of taurine seemed to be negatively correlated with the long-term response of ITP patients toward splenectomy. Taurine is a free amino acid that is abundant in the brain, heart, retina, and platelets. Previous studies have demonstrated that platelet destruction mainly occurs in the reticuloendothelial system of the spleen and liver . Platelee spleen . In addiSo far, several studies have been conducted to identify preoperative and postoperative predictors to assess the efficacy of splenectomy for ITP patients. Age, previous response to glucocorticoids, the principal site of platelet sequestration, and response to intravenous infusion of immune globulin are reported to be preoperative predictors to estimate the outcome of splenectomy . HoweverOther amino acids, such as lysine and phenylalanine, also influence the activation and modulation of immune cells. In addition to amino acids, the role of other discriminatory metabolites, such as 3-hydroxybutyric acid, ethanol, glycogen, and glycerophosphocholine in metabolic reprogramming in the spleen of ITP is still unclear and needs further extensive study.In conclusion, we found the metabolomic alteration of the spleen caused by ITP and screened out discriminatory metabolites distinguishing ITP from the normal in the present study. In addition, taurine was also identified as a potential metabolic marker for the diagnosis and long-term response prediction of ITP. These findings could benefit our understanding of the pathophysiology of ITP and provide new diagnostic and therapeutic strategies.n = 18), pseudocyst (n = 1), and autoimmune pancreatitis (n = 1). All patients had no severe cardiovascular disease, diabetes, deficiency of liver and kidney functions, serious infection, and trauma.The study protocol was approved by the ethics committee of Fujian Medical University Union Hospital, Fuzhou, China, and was conducted in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from all patients. Eighteen spleen samples were collected from ITP patients who received splenectomy in Fujian Medical University Union Hospital from September 2013 to August 2016. Before receiving surgery, these ITP patients had been treated systematically based on international consensus reports and practice guidelines for ITP management and still had refractory thrombocytopenia with a high hemorrhage risk ,25. Twen1H high-resolution magic angle spinning (HR–MAS) NMR spectroscopy, the spleen samples (each approximately 20 mg) were shaped into a sphere and then inserted into zirconia rotors, after soaking with saline in deuterium oxide to maintain osmolality and provide a field-lock. All the 1H HR-MAS NMR spectra were recorded on a Bruker 600 MHz spectrometer equipped with a triple-filed resonance (1H/13C/31P) high-resolution MAS probe operating at a 1H frequency of 600.13 Hz. The tissue samples were spun at 2500 Hz at the magic angle (54.7°) and were maintained at a constant temperature of 288 K. The spectra were acquired using a water-suppressed Carr–Purcell–Meiboom–Gill (CPMG) pulse sequence (RD-90°-(τ-180°-τ)n-ACQ). A spin–spin relaxation delay (2nτ) of 350 ms and a 2 s recycle delay was applied for water presaturation. Typically, 128 transients were acquired with a 32 K data point for each spectrum with a spectral width of 12 ppm.After splenectomy, spleen was divided into 1 cm blocks, packaged in aluminum foil, frozen in liquid nitrogen, and stored at −80 °C. Prior to All free induction decays (FIDs) were multiplied by an exponential weighting function equivalent to line-broadening of 0.3 Hz to increase the signal-to-noise ratio. Then, all spectra were Fourier transformed and manually corrected for the phase and baseline using MestReNova . The double peak of endogenic lactate was employed as a chemical shift reference at δ1.33. The spectral regions of δ9.7–0.7 were integrally segmented into discrete regions of 0.004 ppm and then normalized to the total sum of each spectrum as a constant sum (it is 100 in this study) for multivariate statistical analysis. Resonance assignment and metabolite identification were conducted based on the literature and public databases ,27.2 and Q2 parameters represented fitness and predictive ability of the OPLS-DA model, respectively, to distinguish spleen tissues of ITP from the normal. In addition, the variable importance in projections (VIP) and correlation coefficients (r) of each metabolite obtained from OPLS-DA represent corresponding statistical contributions to the metabolic changes of ITP. The relative concentrations of metabolites, which were calculated by the integral area under the characteristic peaks of NMR spectra, were compared with Student t-test by using SPSS  between the ITP and normal groups. The metabolites with VIP > 1, absolute correlation coefficient |Pcorr| > 0.468 (based on p < 0.05 and df = 16) and p-value of Student t-test less than 0.05 were identified as discriminatory metabolites. A color-code volcano plot was drawn by using Matlab  based on VIP, r, p and fold change of metabolites, where each dot represented a metabolite and a warm-toned color,  and a large size corresponds to a significant difference, whereas a cold-toned color and a small size correspond to no significant difference.To extract the bioinformation contained in the NMR spectra, multivariate statistical analyses were conducted to compare the metabolomes of ITP and normal spleen by using SIMCA . Principal component analysis (PCA) was conducted to simplify complex data into several components to reveal obvious metabolic profiles and identify possible outliers that may interfere with the validation of the analysis. To emphasize the metabolomic differences in the spleen tissues between the ITP and control samples, pairwise comparison was performed using orthogonal partial least squares discriminant analysis (OPLS-DA) with UV-scaling. This OPLS-DA model was then validated with 10-fold cross-validation and the response permutation test (permutation number = 200). The corresponding Rhttps://www.metaboanalyst.ca/, accessed on 20 September 2019) [Enrichment analysis of metabolic pathways associated with ITP was identified based on the differential metabolites by using the Kyoto Encyclopedia of Genes and Genomes (KEGG), Metabolites Biological Role (MBRole), and MetaboAnalyst 4.0 online databases (er 2019) ,29.Wilcoxon rank-sum tests were employed to compare the relative concentrations of metabolites in the spleen between the normal and ITP patients. Chi-squared test and Fisher’s exact test were used to compare statistical differences in the proportion of refractory patients in different groups. Spearman correlation analysis was used to assess the correlation between the postoperative response of ITP patients and the concentration of taurine in the spleen.By using SPSS, the receiver operating characteristic (ROC) curve was used to identify the potential diagnostic ability to distinguish ITP and the normal. p < 0.05 was considered statistically significant.For statistical analysis, 9/L without bleeding), partial response (durative platelet count > 30 × 109/L without bleeding), and no response  groups. This stratification was in accordance with the recommendations of the International Working Group of ITP [The ITP patients were followed up for over 24 months. Based on blood platelet counts and bleeding, the ITP patients were stratified into complete response (CR, durative platelet count > 100 × 10


The intriguing experience that somebody is nearby when no one is actually present and cannot be seen or heard has been reported in many different contexts and has been referred to as the sense of presence, feeling of a presence, invisible presences, or presence hallucination (PH) James, . PHs areHowever, despite its intriguing experiential characteristics and the broad academic and clinical interest, scientific studies and experimental data on PHs continue to be sparse. This is likely due to difficulties in investigating a spontaneously occurring phenomenon, the absence of experimental procedures able to induce PHs reliably in real time, and to their occurrence in the large majority of cases in situations not prone to empirical investigations (far from laboratories). Here we provide an overview of recent investigations in clinical neuroscience on PH and in neuroscience using methods to induce PH experimentally, linking them to altered self-monitoring and sensorimotor processing. We analyze selected spiritual-religious experiences associated with PH and propose a new extended account of PH, by integrating and extending the altered self-monitoring account with the prominent agent detection theory in spiritual-religious experiences Guthrie, . We concThe feeling of presence has long interested psychologists James, , psychiaBased on these data and a prominent model that describes hallucinations as a disturbance or misattribution of self-related predictive sensory signals , beyond mere detection of the presence, based on additional cognitive brain mechanisms .In brief, Guthrie's anthropomorphism account Guthrie, , 2001 li Barrett , 2011, a Barrett  and the as another agent. We argue that invisible presences result not from visual-auditory mechanisms, as argued previously, but from a different perceptual mechanism: motor signals and their integration with somatosensory signals. These somatosensory-motor signals are specific and involve the global self-representation of a person's body  and not the broader, less specific detection of human and non-human agency  is key in PH. We strongly agree with Barrett that intention recognition, mentalizing, and the notion of minimally counterintuitive states are important to consider in PH. However, the involvement of (too) many different perceptual and cognitive functions conceptually seems to over-complexify matters, hindering empirical verification. Moreover, Barrett's proposed list of additional perceptual and cognitive mechanisms, may not be necessary to perceive invisible agents endowed with intentionality. As reviewed above, perceptual somatosensory-motor mechanisms related to a person's global self-representation are sufficient to perceive an intentional presence and fit well within the category of minimally counterintuitive states . Key aspects of supernatural agent detection, as noted by Barrett and Guthrie, are also accounted for by the self-monitoring proposal. We argue that these different accounts are not mutually exclusive: it is rather likely that self-related (egocentric) and environment-related  mechanisms are complementary, although we argue that the self-monitoring account is the primary and most basic mechanism of supernatural agent-detection. Finally, the narrative style of both earlier theories has made it difficult to empirically test them, leading to numerous studies with conflicting results , by National Center of Competence in Research (NCCR Synapsy 51NF40-185897), Parkinson Suisse, and Bertarelli Foundation. This paper is funded by Dr. Rüdiger Seitz, via the Volkswagen Foundation, Siemens Healthineers, and the Betz Foundation. The authors declare that Siemens Healthlineers was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.OB is an inventor on patent US 10,286,555 B2 (Title: Robot-controlled induction of the feeling of a presence) held by the Swiss Federal Institute (EPFL) that covers the robot-controlled induction of the feeling of a presence (PH). He is an inventor on patent US 10,349,899 B2  held by the Swiss Federal Institute (EPFL) that covers a robotic system for the prediction of hallucinations for diagnostic and therapeutic purposes. He is a cofounder and shareholder of Metaphysiks Engineering SA, a company that develops immersive technologies, including applications of the robotic induction of PHs. He is member of the board and shareholder of Mindmaze SA. The remaining 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.