Aims This study explores the prevalence of being a past-year affected other (AO) of a problem gambler by gender. The aims were to study the amount and type of gambling-related harms (GRHs) for subgroups of AOs and to distinguish GRH profiles for AO subgroups. Methods A total of 7186 adults aged 18 years and over participated in the Gambling Harms Survey evaluating year 2016. The data were analyzed using descriptive statistics and binary logistic regression. Results Of all respondents, 12.9% were defined as past-year AOs . The proportion of affected non-family members (ANFs) was 8.4%, and 5.6% were affected family members (AFMs). AFMs were usually women, and ANFs were usually men. Emotional, relationship, and financial harms were the most common types of harm. The odds of experiencing financial harm were highest for the 18- to 34-year-olds (OR 1.82) and for those whose partner/ex-partner had a gambling problem (OR 3.91). Having a parent/step-parent (OR 1.93) and child/stepchild (OR 3.64) increased the odds of experiencing emotional harm, whereas male gender (OR 0.50) and being an ANF (OR 0.58) decreased emotional harm. Relationship harm was evident for partners/ex-partners (OR 1.97–5.07). Conclusions GRH profiles for AO subgroups varied, which emphasizes the need for effective harm minimization strategies for those in need. The recent research scope has been broadened to look at different types of gambling-related harms and identify who is encountering these harms ,2. BasedThe term affected other (AO) is used to refer to persons who have or have had close ones with problematic gambling. The term AO does not imply relationship status or any level of concern . AO is uThe prevalence of AOs varies, drawn from epidemiological studies from 2 to 19 percent, depending on methodology, timeframe, and definitions used ,17,18,19The link between health issues, including a gambling problem of one’s own, poor perceived health, psychological distress, and risky alcohol consumption and being an AO was clearest among the affected family members (AFMs) ,16,17,18Problem gambling affects the family as a whole. Gamblers’ partners report severe emotional and psychological harms, such as feelings of extreme distress, hopelessness, and vulnerability, as well as stress-related health harms including insomnia, headaches, and high blood pressure ,10,12,21Gambler’s children have an elevated risk for developing gambling problems themselves and engaging in other risky behaviors such as alcohol consumption, smoking, and substance abuse . GamblinParents and grandparents of a problem gambler report diminished enjoyment of life, physical and emotional stress-related symptoms, financial harms, and relationship harms. Trying to help by lending money or paying the gambler’s debts or dealing with the loss of money or sold household items is common and causes mixed harms to AOs.Although AFMs experience GRHs more often and to a greater degree than an affected non-family member (ANF), ANFs still experience a substantial amount of GRHs. According to previous studies, the person experiencing GRH is most often a close friend of a problem gambler ,26, yet GRHs at the workplace are identified by numerous studies, which conclude that gambling at work means that the worker is not fulfilling their part of the employment agreement. Gambling even during leisure time may affect work performance (inefficient work), absenteeism, and tardiness at work—being preoccupied with gambling at work and experiencing withdrawal symptoms or asking for loans from co-workers ,28,29,30Previous research concerning GRHs of AOs has focused mainly on the problem gambler’s family, especially the partner’s experiences, while little is known from the perspective of ANFs. Besides, ANFs (namely friends) have been recognized better than other non-family members. Our aim is to explore the prevalence of being an AO of a problem gambler by gender, and the amount and type of GRHs for subgroups of AOs and to characterize unique GRH profiles for AO subgroups.In this study, we use the first wave of data from the population-based Finnish Gambling Harms Survey ,30 condun = 67) were removed from the sample. Therefore, the final sample consisted of 19,933 persons. The final response rate was 36.1% since 7186 adults participated in the survey.The data were collected between January and March 2017 from adults aged 18 years and over. Both web and postal surveys were available in both official languages, Finnish and Swedish. A total of 20,000 potential participants were randomly selected from the population information system and were invited to the study with an invitation letter and a brochure. Oversampling 18 to 24-year-olds compensated for the low participation rate expected based on previous surveys [n = 5084) participated using the online survey, whereas 29% (n = 2102) participated through the postal survey [SD = 18.4) [Of the respondents, 71%  .Affected others (AOs) were evaluated by inquiring: “During the year 2016, has there been a person in your life that you consider gambles too much?” ,32. If tTable 1GRHs for AOs were questioned using 12 response options . In addiIn addition, the data contained register-based information about the respondents’ gender and age. Age was dichotomized into two age groups: 18−34, and 35 and up.p) were calculated with Chi-Squared and Fisher’s exact tests. All selected variables were dichotomized and added simultaneously into the logistic regression models. Furthermore, health-related harms, work/study harms, and social deviance harms were combined for the model and named other harms due to the small number of respondents in some subcategories. To optimize the model, gender and age were added. All analyses were done using SPSS version 27.0 .The age, gender, and regional distributions were used to calibrate the data weights. Percentages and significance  or a parent or step-parent (1.7%). Among ANFs, the problem gambler was most commonly a friend (4.6%) or a co-worker (1.4%). The proportion of those with a friend and co-worker with a gambling problem was higher among men.More than half (58.3%) of the AOs did not experience any harm . Among AEmotional harms, relationship harms, and financial harms were the three most common types of past-year harms for AOs—both AFMs and ANFs . Among tOf family members, the highest prevalence of experiencing at least one harm type was among those with ex-partners (70.8%), a child or stepchild (64.8%), or other family members (64.2%) with a gambling problem . The proThe odds of experiencing financial harms were significantly increased for 18 to 34-year-olds (OR 1.82) and for those whose partner or ex-partner had a gambling problem (OR 3.91) . FurtherThis study explored the prevalence of being an AO of a problem gambler by gender. In addition, it focused on the amount and type of GRHs for AOs, including both AFMs and ANFs, and distinguished the GRH profiles for AO subgroups. A past-year time frame was used; therefore, this study differs from previous Finnish studies on the same topic, which were conducted using a lifetime frame ,14,19.As expected, the AFMs were typically women. However, ANFs (including both friends and co-workers) were typically men. Similar gender differences have been seen among both the general population ,19,21,32Our results confirmed that emotional harms, relationship harms, and financial harms were the three most common types of past-year harms for the AOs ,10,11. DEmotional harms were experienced largely by AFMs (43.1%) and less than half by ANFs (21.1%). Based on previous research, affected partners report that gambling impacts their daily life and brings distress, a desire to escape the relationship, a sense of hopelessness, and helplessness . It is oIn our study, emotional harms were most common and enhanced if the child or stepchild or partner or ex-partner was the problem gambler. This implies that emotional harm may be perceived differently, depending on the type and depth of the relationship but also depending on the distance from the gambler. For example, a person living in the same household with a problem gambler may experience distress to handle the household finances and daily errands because the gambling problem may limit a person’s ability to commit and share duties equally. Additionally, family members living with a problem gambler may have to constantly face the GRHs without any possibility to withdraw.Affected partners and also ex-partners came across various harms rather commonly. Based on our model, relationship and financial harms were exceptionally frequent among the affected partners or ex-partners. Relationship harms have been reported by partners as being five to six times higher than the gambler’s perception of the state of the relationship . These dAround one in ten AOs had experienced financial harms. Being an affected partner often means taking responsibility for running the household finances . In someOn the other hand, gambling and problem gambling can occur anywhere, even in the workplace. The proportions of harms for ANFs were mostly lower than those of AFMs, but work- and study-related harms were more common among the ANFs. In fact, there are some specific work fields—such as the transport sector, shift work, building, construction and service, monotonous manual indoor work, and work that requires frequent traveling ,28,30 whAs per our results, GRHs vary in different subgroups. The first point is to increase public and professionals’ awareness of the gambling phenomena  and to lower the bar of directly asking whether such a problem exists. The availability of low-threshold support or treatment options for AOs is still non-existent or limited, at least in Finland. Not all AOs report GRHs, and in turn, we do not know well enough who are the AOs that require support and what type of support; thus, this is an area worth investigating in the future. It could well be that the psychoeducational components of problem gambling (understanding a gambler), securing one’s own finances, and building clear boundaries to secure one’s own well-being delivered online as self-help ,39,44 maFurthermore, recognizing gambling in the workplace can be challenging since people are often not aware of the magnitude of gambling problems or even that the person close to them is gambling  due to iIt would be useful for policy makers to understand to what extent emotional, financial, and health harms are more widespread and prevalent than the ones experienced solely by the gamblers themselves. In fact, it has been estimated that problem gambling affects approximately six persons per gambler .In this study, only the personal views of AOs of problem gamblers were recorded, and no validated instrument was used. The prevalence rates of AOs were assessed using self-assessment method and a life-time frame. Even though it would be interesting to compare the prevalence of AOs along with the prevalence rate of problem gambling from the gamblers perspective, the comparison is not advisable due to the methodological differences. For example, the prevalence rate of problem gambling has been around 3 percent in Finland, but the South Oaks Gambling Screen was used with a past-year time frame. Furthermore, many subgroups of respondents and subcategories of GRHs were combined for the models due to low frequencies. Overall, the results are presented only if the frequency in the subcategory was above five, and this may have meant missing some detailed information. Additionally, non-significant findings may be explained by the small number of participants in some subgroups, even though the corresponding OR suggests an association between the variables. In our study, respondents could choose multiple options for the question about the respondent’s relation to the person with a gambling problem. Therefore, although the same question was used on our respondents, the results are not directly comparable with the results of the previous two studies where respondents were advised to choose only one option ,32.The AFMs were typically women, and ANFs (including both friends and co-workers) were typically men. Emotional harms, relationship harms, and financial harms were the three most common types of past-year harms for the AOs. Affected partners experienced various harms and rather commonly. Relationship and financial harms were exceptionally typical among both affected partners and ex-partners. Emotional harms were utmost distinctive. The most common and notable emotional harms were if the child or stepchild or partner/ex-partner was the problem gambler. About one in ten AOs had experienced financial harms. Even though the proportions of harms for ANFs were mainly lower than those of AFMs, the work- and study-related harms were more common among the ANFs. Given the significant proportion of AOs and the variety of GRHs they encounter regardless of subgroups, there is a need to implement preventive efforts, community training, and tailored intervention to minimize the harms of AOs.


Background: Despite the quantitative information derived from testing of the CSF circulation, there is still no consensus on what the best approach could be in defining criteria for shunting and predicting response to CSF diversion in normal pressure hydrocephalus (NPH). Objective: We aimed to review the lessons learned from assessment of CSF dynamics in our center and summarize our findings to date. We have focused on reporting the objective perspective of CSF dynamics testing, without further inferences to individual patient management. Discussion: No single parameter from the CSF infusion study has so far been able to serve as an unquestionable outcome predictor. Resistance to CSF outflow (Rout) is an important biological marker of CSF circulation. It should not, however, be used as a single predictor for improvement after shunting. Testing of CSF dynamics provides information on hydrodynamic properties of the cerebrospinal compartment: the system which is being modified by a shunt. Our experience of nearly 30 years of studying CSF dynamics in patients requiring shunting and/or shunt revision, combined with all the recent progress made in producing evidence on the clinical utility of CSF dynamics, has led to reconsidering the relationship between CSF circulation testing and clinical improvement. Conclusions: Despite many open questions and limitations, testing of CSF dynamics provides unique perspectives for the clinician. We have found value in understanding shunt function and potentially shunt response through shunt testing in vivo. In the absence of infusion tests, further methods that provide a clear description of the pre and post-shunting CSF circulation, and potentially cerebral blood flow, should be developed and adapted to the bed-space. It has been over 50 years now since infusion tests were introduced directly into bedside practice, as a method of assessment of the CSF dynamics and circulation systems.Thirty years elapsed since, we started performing them in Cambridge hydrocephalus clinic day cases and neurosurgical inpatients ,2,3,4. IHydrocephalus is currently perceived as either the life threatening, acute ventriculomegaly with increased intracranial pressure, or the more chronic form of “normal pressure” hydrocephalus, that could potentially be reversed by augmentation of patient’s CSF outflow by a shunt. An accurate, careful process of selecting those patients for shunting ,16,17,18In most cases of hydrocephalus patients, we would most likely be trying to interpret a CT or rarely an MRI with obviously dilated ventricles, with or without signs of periventricular lucency. Radiological indications of raised pressure, cerebral atrophy, and ex-vacuo dilatation ,20,21,22Based on the current definition and clinical axioms of this decision process, the reports of improvements are between 40–80% of shunted cases ,28,29,30The role of assessment of CSF dynamics is particularly important from the perspective of the treatment of hydrocephalus patients. Insertion of a shunt dramatically alters the CSF circulation and hydrodynamics properties of the cranio-spinal system. Therefore, the knowledge about the system that we are going to modify and manage in the long term, appears to be vital. In many, if not all cases, apart from checking CSF dynamics, it should involve CBF studies ,39,40,41In this review, we aimed to demonstrate the lessons learned from assessment of CSF dynamics in our center and summarize our findings to date. We do not aim to make any clinical recommendations as these findings are mainly centered on the science behind CSF circulation testing, as well as retrospective comparison with clinical practice and outcome. We will simply give an overview of the CSF dynamics perspective, a very focused and specific perspective compared to the overall individual clinical approach of patients in modern, personalized medicine. CSF infusion tests, the procedure, data recording, analysis, and interpretation have been exhaustively detailed in numerous publications and do not fall within the scope of this review ,55,56,57Infusion test offers several advantages and alternatives compared to ICP monitoring . BesidesWith the advancement of imaging technology, as well as ICP monitoring and shunt technology, infusion tests can easily be combined with different methods. This can be performed in order to assess additional parameters of the cerebral mantle, white matter, and cerebrovascular reactivity, as well as retrieve complementary information required to fully assess patients  ,63,64,65One of the mainstays of our decades of scientific data is that ICP is not a number, but a continuous, complex variable determined by many factors ,71,72,73We have previously illustrated this phenomenon with many examples of long-term ICP monitoring and infusion tests. The typical pattern of NPH CSF dynamics consists of normal baseline ICP and a raised Rout. Early scientific experiments in physiological individuals defined the normal range of Rout from 6–10 mmHg*(min/mL) ,98,100. Studying and validating Rout and other CSF dynamic parameters in physiological individuals naturally provides cleaner data and easier interpretation. Determining a clinically useful threshold, however, has proven a lot more complex and the reasons behind this are multiple and might fall beyond the scope of this review. Based on the physiological data, the hydrocephalus practice in Cambridge has generally been to utilize the threshold of 13 mmHg*(min/mL) in combination with the corresponding clinical and radiological findings of NPH in order to support decision-making for offering shunting to patients. This threshold was based on late 20th century evidence of very optimistic prognostic values of Rout > 12. Twenty-first century evidence has conversely brought to light larger ranges of Rout among shunt responders and non-responders. A summary of the available evidence on Rout is shown in On a different note, it might be possible to establish a lower threshold for Rout that could indicate significant atrophy, and therefore no response to shunting, or in other cases CSF leak. If ICP alone provides us with minimal to no information about the pressure equilibrium in the brain, ICP combined with Rout allows for a rudimentary 2-D classification of CSF disorders. Pulse amplitude can be calculated as the peak-to-peak amplitude of the ICP waveform, i.e., the difference between the systolic and diastolic peak of the wave or as the fundamental amplitude of the first harmonic of the ICP pulse waveform, as calculated in ICM+ ,114,115.During infusion, both in physiological individuals and patients with NPH, AMP rises in close linear relationship to ICP. When plotting this linear relationship during the entirety of the infusion test, the slope of the amplitude-pressure (AMP-P) line can be calculated through simple linear regression. The AMP-P relationship may already be linear from baseline, or show a lower breakpoint, above which a strong linear relationship begins and below which the line become horizontal . An incrSimilar to the AMP-P slope, RAP is derived from the correlation of AMP and ICP and calculated as their time-moving correlation coefficient. Lack of a direct linear relationship (RAP closer to 0) overall reflects a state of adequate compensatory reserve in the cerebrospinal compartment, as is expected in healthy subjects, but also in cases of atrophy. As the compensatory reserve becomes depleted, RAP values are closer to 1. Depleted ccompensatory reserve at baseline (i.e. before the start of infusion) has in its turn been associated with higher rates of improvement after shunting. However, RAP calculation during infusion tests can be technically challenging, as it requires at least 5 min windows of clean data, and it is not infrequent for patients to move and generate artefacts during such a period ,117,121.Elasticity has been studied in NPH to a lesser degree compared to all the other parameters, as it plays an uncertain role in NPH pathophysiology. Elasticity has shown no superiority to the remaining pressure–volume compensation parameters in predicting outcome after CSF diversion, with potentially the exception of ETV outcome in patients with aqueductal stenosis ,124,125,Slow waves of ICP are oscillations correlated with the cerebral blood volume vasocycling and can be automatically detected by frequency analysis either during CSF infusion tests or from overnight ICP monitoring ,127,128.There is currently very weak evidence about any diagnostic and/or predictive value of CBF and autoregulation in NPH. However, there is a need to address the CSF-CBF crosstalk. Examples from traumatic brain injury patients with intracranial hypertension attribute rises in ICP to vascular rather than CSF factors up to 70% of the time ,146,147.What we can observe through the use of infusion tests and analysis of ICP components, in combination with other methods, are the following:Slow waves, as observed in ICP recordings during infusion tests, are sometimes referred to as vasogenic waves due to the dominant, but not proven, explanation of their origin ,136,148.The coefficient Mx is calculated as time moving window correlation between the slow waves of cerebral flow velocity and cerebral perfusion pressure. Another reactivity index, PRx, could be assessed during infusion tests using the slow waves of ICP and preferably non-invasive ABP . The more positive Mx and PRx are, the more “passive” the cerebral vascular & pressure system, therefore, autoregulation is impaired and ABP or even ICP changes would passively result in impaired CBF ,159,160.In patients with clinical/radiological symptoms of NPH, the two indices described in a previous point (Mx and PRx) are known to negatively correlate with Rout. With high resistance patients tending towards preserved autoregulation, compared to those with normal and lower normal Rout, who tend towards positive values  7,60,16,1660,161A more precise, albeit limited in clinical practicality, the right method to address relationship between impaired autoregulation, reduced baseline CBF, and the resulting cerebral and clinical impairments, is neuroimaging. Using PET/MRI combined with infusion tests, we have managed to explore the relationship between Rout, cerebral perfusion pressure, CBF, and autoregulation in NPH. What we showed in healthy, age-matched volunteers was that CBF and autoregulation appear constant and unchanged globally, without regional variations. Global CBF and autoregulation appeared reduced in NPH subjects; however, this was influenced by significant regional impairment of those values in the white matter most proximal to the ventricles  63,64,6,664,65. The events that will follow a shunt implantation are the most significant ones, as the procedure itself is nowadays adequately safe and aimed at minimizing mortality and morbidity. What indeed could eventually guide the decision and planning of shunting NPH patients, would be the ability to deal with the sequelae of managing an intracranial device and its many complications and malfunctions ,183,184.Our methodology of in vivo shunt assessment is based on experience in studying CSF dynamics and data from the UK shunt Laboratory. The method uses an infusion test and appropriate interpretation of the results.Based on the data from the shunt testing in-vitro, we can assign specific attributes to the implanted shunt system, which appears to be crucial for functioning and consequently an assessment of the implanted shunt. These are: opening pressure, below which no drainage take place; shunt’s hydrodynamic resistance ); and a critical pressure, the pressure value which an adequately working shunt should not allow to be exceeded during infusion test ,195,196.An important point to bear in mind is that any recorded ICP signal should be pulsatile; if no appropriate ICP pulsation  is detected, then whatever pressure is being recorded does not correspond to ICP. Therefore, if in the pressure signal detected from the shunt prechamber, the pulse amplitude is not detected, this is a prerequisite for conclusion about proximal obstruction.The number recorded could be a random pressure in the isolated shunt pre-chamber not consistent with real patient’s ICP. Empirical assessments of shunt patency through “pumping” on the pre-chamber repeatedly or attempting to aspirate both to assess proximal patency and to aspirate large volumes of fluid are not only misleading but potentially dangerous; derived dangers are due to the fact that these interventions generate uncontrollable negative pressure in the ventricular system. We have previously demonstrated, in a lab environment, how pumping can generate severe intracranial hypotension, even down to −230 mmHg .Shunt testing in vivo, in its entirety, is a subject on its own and involves diagnosing many other complex issues that could occur. We have described them in numerous occasions, including underdrainage, over-drainage and postural over-drainage, and partially obstructed ventricular catheters. The conclusion that the chosen shunt did not possess hydrodynamic parameters suited to the individual’s CSF dynamics and drainage requirements ,106,200 In summary, before deciding on a patient’s outcome, it is essential to gather as much objective evidence as possible that the shunt system functions adequately. Unless non-responders are tested further for such possibility, outcome measurement is rendered null and void. If in a research setting we were able to test more shunt responders , insights into the CSF circulation post-shunting in the two categories (responders vs non-responders) could help us understand more about the reasons of shunt failure in NPH. Finally, securing adequate CSF drainage, in balance with avoiding the consequences of over-drainage in the elderly, constitutes a separate issue that requires consideration. It is likely that patients with low baseline ICP, low resistance to CSF outflow, and no overnight spikes in ICP above values that will allow the shunt to open and drain CSF may still not be receiving adequate drainage, or any drainage at all, and as such, any inferences related to their outcomes are also invalid.Even extended lumbar drainage, which ensures a controlled amount of CSF drainage, could subsequently not correlate to shunt response in such a scenario. Interestingly, extended lumbar drainage, which provides controlled drainage over a prolonged period of time (3–5 days), could provide more reliable information in relationship to outcome, as the confounding factor of variable drainage is accounted for. However, 3–5 days of drainage by themselves are often inadequate for assessing response in NPH, as it has been shown that improvement in many cases could be delayed and could take several weeks or months ,204,205.Considering all of the above, concluding who requires a revision and who does not, using CSF dynamics appears an easier question to answer than when to implant a shunt in the first place. Consequently, we have been able to address this question in a clinical as well as a theoretical context and have shown the feasibility and safety of shunt infusion tests both in paediatric and in adult patients with non-acute hydrocephalus ,40,43,57Pulsatile ICP, within the expected limits for the shunt operating pressure, normal resistance, and critical pressure (inherent property of the shunt) not exceeded during infusion: no revision, the shunt is patent and draining well.Non-pulsatile “pressure” at baseline, steep jump in pressure after start of infusion, and no signs of pulse waveform recovery during infusion: proximal obstruction. If distal catheter is patent (seen by stabilization of pressure after infusion), it can proceed to revise only the proximal catheter.Clearly raised, pulsatile baseline pressure: distal obstruction . Ventricular catheter patent can revise only the distal end .Normal opening pressure, with significant rise in ICP during infusion to values clearly exceeds shunt critical pressure; raised Rout: distal obstruction .ICPp slightly exceeding critical pressure; Rout mildly raised: mild underdrainage, consider adjusting the setting and monitor, which may require revision later.To summarise, from a CSF dynamics perspective, some examples who should undergo shunt revision surgery are shown in The issue of post-operative shunt functioning brings us back to the problematic relationship between CSF dynamic parameters and clinical outcome.We have summarised below the main lessons learned from our cumulative work of both research as well as clinical implementation of CSF dynamics. We are highlighting the fundamental principles of balancing scientific principles and clinical practice by avoiding caveats of using either approaches in isolation .Unfortunately, as shown recently by the randomized European iNPH trial, as well as single-centre analysis, CSF dynamic picture and particularly Rout are far from perfect outcome determinants ,105. RouHowever, it should be reiterated that an evaluation of hydrodynamics of the cerebrospinal compartment is helpful in patients management, particularly from the perspective of treatment: with a shunt, by which we interfere with the CSF circulation system.In order to investigate the value of those added parameters in shunt prognostication, we have recently performed an analysis of 369 patients from our center that were shunted as a result of their CSF dynamics and full clinical investigations . We wereThese relatively disheartening numbers could lead us to abandoning any effort of testing CSF circulation, as 70% predictive power is not superior to shunting everyone based on the presence of ventriculomegaly and clinical symptoms. It would not be prudent though to rush to such conclusions before considering everything we have discussed in this review. Firstly, we could conclude that CSF dynamics are misleading and of no clinical use. This would entail us to dismiss all data and evidence summarised in this paper and preclude us from taking a step back and thinking that the limitations we face could be in the CSF dynamics, or equally in the way we currently diagnose, follow-up, and define shunt response. Considering all the missing information on how much a shunt in situ drains in NPH and how occult NPH shunt malfunction/obstruction or inadequate drainage may be, shunt response should be carefully reconsidered and redefined. Moreover, given our opening statement on the complexity of NPH that includes a strong vascular component and interaction with the CBF, a CSF circulation and pressure-volume compensation descriptor could more successfully be combined with an autoregulation/ pressure reactivity descriptor, as initiated by the existing studies on CBF and autoregulation in NPH.To close the circle of the CSF dynamics—improvement after shunting continuum, we bring you back to the argument that objective testing of CSF dynamics should be followed by objective definition and post-shunting description of shunt response. No response to shunting is rarely followed-up to such completion, as there are currently limited tools available (besides CSF infusion tests).Ultimately, without assessing outcome, the CSF dynamics perspective suggests the following; see To improve the utility of the CSF infusion test in relationship to clinical outcome and based on the overview given at the current review, the shunt process can be the following —Again, please be reminded that this is not a clinical or guidance proposal, it is simply the logical derivative of the perspective and overview we have provided in this work.Rout is an important biological marker of CSF circulation. It should not, however, be used as a single predictor for improvement after shunting. No single parameter from the CSF infusion test could undertake this role either. Testing of CSF dynamics provides a bedside tool to enhance our understanding of NPH and the process of its reversal. It can be combined with other tools, support clinical practice, and become a strong ally to neurosurgeons who aspire to practice precision medicine. It allows to diagnose the hydrodynamic properties of the cerebrospinal compartment, the system, which is being modified by a shunt, hence altering its hydrodynamic properties. Therefore, it provides the baseline for patient’s management. We emphasize the importance of shunt testing in vivo both in the context of suspecting malfunction, as well as in improving management of the patient and outcome assessment in NPH. Our experience of nearly 30 years of studying CSF dynamics in patients requiring shunting and/or shunt revision, combined with all the recent progress made in producing evidence on the clinical utility of CSF dynamics, has led to reconsidering the discrepancies between CSF circulation testing and clinical improvement.Patients have changed in the last 50 years since the early works on Rout and infusion tests; neurosurgery has changed and shunt technology is moving forward. We could attempt at adapting infusion tests and our objective investigations, the only stable constant of the last 4–5 decades, to keep up with those changes and find out whether they could serve this purpose or not. Further studies on this direction could help us address this issue and reach a consensus.


The OsMYBS2 transcription factor was shown recently to reduce activation of the αAmy3 promoter by competing for the binding site of the TA box of the αAmy3 promoter with the potent OsMYBS1 activator. In this study, rice suspension cells were genetically engineered to silence OsMYBS2 to enhance the production of recombinant proteins.Transgenic plant suspension cells show economic potential for the production of valuable bioproducts. The sugar starvation-inducible rice αAmy3 promoter and expressed in OsMYBS2-silenced transgenic rice suspension cells. Transcript levels of the endogenous αAmy3 and the transgene mGM-CSF were increased in the OsMYBS2-silenced suspension cells. The highest yield of recombinant mGM-CSF protein attained in the OsMYBS2-silenced transgenic suspension cells was 69.8 µg/mL, which is 2.5-fold that of non-silenced control cells. The yield of recombinant mGM-CSF was further increased to 118.8 µg/mL in cultured cells derived from homozygous F5 seeds, which was 5.1 times higher than that of the control suspension cell line.The mouse granulocyte–macrophage colony-stimulating factor (mGM-CSF) gene was controlled by the OsMYBS2 increased the activity of the αAmy3 promoter and improved the yield of recombinant proteins secreted in rice cell suspension cultures.Our results demonstrate that knockdown of the transcription factor gene The online version contains supplementary material available at 10.1186/s13007-021-00799-2. Plant molecular farming is a technology used in genetic engineering whereby plants are used to produce valuable therapeutic recombinant proteins and secondary metabolites by transferring recombinant gene(s) to plant hosts . With clALPHA-AMYLASE 3 gene  promoter, which is induced strongly by sugar starvation [αAmy3 allows recombinant proteins to be secreted into the liquid medium, thereby avoiding cell lysis and the complicated steps required for protein purification [αAmy3 promoter and signal peptide in cultured cells of transgenic rice cell suspensions [αAmy3 promoter has been used widely for sugar-regulated recombinant protein production [αAmy3 promoter based-recombinant production system. For example, knockdown of endogenous αAmy3 expression increased recombinant human GM-CSF production 1.9-fold in transgenic rice cells [CYSTEINE PROTEASE gene in transgenic rice cells resulted in an increase in the yield of recombinant human GM-CSF [For the production of recombinant proteins, the host cells of rice and tobacco are those used most frequently in plant suspension cultures. The best-known system of transgenic rice cell suspension culture is based on the rice arvation . The sigfication . Severalpensions –16. Althoduction , rice cece cells ; silencin GM-CSF .αAmy3 [αAmy3 promoter is an essential regulatory motif for potent activation of the αAmy3 promoter in sugar-starved rice cells [αAmy3 is achieved by competitive binding between OsMYBS1 and OsMYBS2 to the TA box of the αAmy3 promoter [OsMYBS2 in transgenic rice cells, a lower level of OsMYBS2 is essential for potent activation of the αAmy3 promoter under sugar depletion [Sugar signals mediate transcriptional regulation of αAmy3 . A duplice cells , 19, 20.ce cells , 22. Regpromoter , 23, whepromoter , 22. BasGranulocyte–macrophage colony-stimulating factor (GM-CSF) is an immune-response cytokine generated by macrophages, endothelial cells, and immune-stimulated fibroblasts –28. The αAmy3 promoter-based transgenic rice suspension cells with mGM-CSF demonstrated to accumulate to a maximum yield of 24.6 mg/L attained in a 2 L bioreactor [αAmy3 promoter by competing with OsMYBS1 for binding to the TA box of the αAmy3 promoter [In a previous study, we produced mGM-CSF using oreactor . The trapromoter . TherefoαAmy3p::mGM-CSF [Ubip::OsMYBS2RNAi [Agrobacterium-mediated transformation [αAmy3p::mGM-CSF transgene contains a rice sugar depletion-inducible promoter, αAmy3p, and an αAmy3 signal peptide DNA fused upstream of the mGM-CSF gene  region at the 3ʹ untranslated region of OsMYBS2 cDNA fused at the up- and downstream ends of a GFP coding sequence, under the control of the maize ubiquitin gene (Ubi) promoter  [Seeds of the Foog (MS)  solid meoog (MS)  liquid mg for 20 min, and post centrifuging, the sample supernatant was collected. One-fifth the volume of isopropanol was added to the supernatant for DNA precipitation. The sample was then centrifuged at 10,000×g for 20 min to pellet the DNA. After air-drying, the DNA pellet was dissolved in 50 µL ddH2O and preserved at − 20 ℃. One microgram of each genomic DNA sample was subjected to PCR using the following gene-specific primers: for amplification of mGM-CSF DNA, 5′-ATGGCACCCACCCGCTCACC-3′ and 5′-AAAAAACCAGTCCAAAAATGA-3′; for amplification of OsMYBS2RNAi DNA, 5′-AAAGGATCCCTCGAGATGGTGAGCAAGGGCGAG-3′ and 5′-GGGATCCTATCTAGACTTGTACAGCTCGTCCAT-3′; and for amplification of ACTIN-1 (ACT1) DNA, 5′-CTGATGGACAGGTTATCACC-3′ and 5′-CAGGTAGCAATAGGTATTACAG-3′. The PCR products were separated by electrophoresis in 0.5 X TAE buffere at 100 V.Genomic DNA was isolated from 2-week-old seedlings or calli . The ricg for 20 min at 4 ℃ to collect the supernatant. Next, 250 μL isopropanol was added to the supernatant to precipitate the total RNA. After 10 min of incubation at room temperature, the sample was centrifuged at 10,000×g for 20 min at 4 ℃ to pellet the total RNA. The RNA pellet was washed with 500 μL of 75% ethanol. After removing the 75% ethanol wash, the RNA pellet was dried at room temperature for 10 min. The RNA pellet was than dissolved in 50 µL DEPC-treated water. Isolated total RNA was treated with RNase-free DNase I  to remove possible DNA contamination. First-strand complementary DNA (cDNA) was synthesized from 2.5 µg total RNA using ReverTra Ace® reverse transcriptase  with oligo-dT primers. A tenfold dilution of the resultant first-strand cDNA was subjected to qRT-PCR with mGM-CSF, OsMYBS2, and αAmy3 gene-specific primers using the FastStart Essential DNA Green Master  and the PikoReal™ Real-Time PCR system . For detection of mGM-CSF mRNA, the aforementioned specific primers for amplification of mGM-CSF DNA were used. The primers 5′-GGACTCGAGAATGGAGCAGCATGAGGA-3′ and 5′-GTCCATGGTACCCCTTTCTT-3′ were used for detection of OsMYBS2 mRNA, and the primers 5′-GTAGGCAGGCTCTCTAGCCTCTAGG-3′ and 5′-AACCTGACATTATATATTGCACC-3′ were used to detect αAmy3 mRNA. The qPCR procedure was repeated independently at least three times. Expression of ACTIN-1 in rice suspension cells is repressed in sugar free medium, so 18S rRNA was applied as a reference gene for normalization in detection of gene expression under sugar starvation treatments. The primers used to detect 18S rRNA were 5′-CCTATCAACTTTCGATGGTAGGATA-3′ and 5′-CGTTAAGGGATTTAGATTGTACTCATT-3′. The relative gene expression level was expressed as the ratio of the target gene mRNA abundance to the 18S rRNA abundance. Data were analyzed using PikoReal 2.0 software (Thermo).Total RNA was isolated from caill as described previously . The ricProtein gel blot analysis was performed as described previously  and the The concentration of rmGM-CSF in the culture medium was determined by sandwich ELISA following the method described by Liu et al. . The goaOsMYBS2-knockdown rice suspension cells, a dihybrid cross approach was used to generate the OsMYBS2-knockdown and mGM-CSF-expressing transgenic rice plants. The homozygous transgenic rice harboring the αAmy3p::mGM-CSF transgene  protein, the rmGM-CSF protein productivity was compared among two mGM-CSF control cell lines, G3 and G5, and two mGM-CSF/OsMYBS2-RNAi cell lines, GS2Ri1 and GS2Ri4. Cell suspensions were cultured in sugar-containing N6 medium for 3 days, and then 1.0 mL of cultured cells was incubated in 2.0 mL sugar-free N6 medium for 5 and 7 days. The cultured medium of each cell line was collected and an equal amount of total medium protein from each line was analyzed by western blot analysis. After sugar starvation for 5 days, the amount of recombinant mGM-CSF (rmGM-CSF) protein detected in the sugar-free liquid N6 medium of the GS2Ri1 and GS2Ri4 cell lines was considerably higher than that detected in the medium of the control cell lines G3 and G5  were cultured in sugar-free N6 medium for various periods and protein yields of rmGM-CSF were monitored using an enzyme-linked immunoassay (ELISA). Similar to a previous report , rmGM-CSOsMYBS2 expression accelerated the accumulation of rmGM-CSF protein in the medium, which may be caused by rapid stimulation of αAmy3 promoter activity in response to sugar depletion in the presence of reduced OsMYBS2 abundance. Acceleration of the αAmy3 promoter response to sugar depletion is particularly advantageous for production of recombinant proteins by the αAmy3 promoter-based recombinant protein expression system because it shortens the duration of recombinant protein production and reduces cell damage. In addition, recombinant protein production is maintained at relatively stable levels under repeated cycles of the presence and absence of sugar by the same batch of rice suspension cells [In the rice suspension culture recombinant protein expression system, cells are initially generally cultured in a sugar-containing medium for cell proliferation and growth. The recombinant protein is produced after cells are transferred to a sugar-free medium. However, when recombinant proteins are produced from sugar-starved cells, the cell viability decreases , 38, 43.on cells , 43. An αAmy3p::mGM-CSF and Ubip::OsMYBS2RNAi transgenes. Based on genetic laws, F1 progeny should be heterozygous at both loci (OsMYBS2RNAi and mGM-CSF transgenes), so only one copy of each transgene existed in F1 seeds. After self-pollination of F1 plants, dihybrid homozygous transgenic rice plants that contain two copies of each transgenes, OsMYBS2RNAi and mGM-CSF, can be obtained in F2 population. Genotype analysis of progeny from self-pollinated F2 plants revealed that all 86 analyzed individuals from either GS2Ri1 or GS2Ri4 parents were mGM-CSF only or mGM-CSF/OsMYBS2RNAi transgenic lines (Additional file 3 population was homozygous for the mGM-CSF transgene, but remained heterozygous for the OsMYBS2RNAi transgene. Genotype analysis of the F4 progeny showed that both mGM-CSF and OsMYBS2RNAi transgenes were homozygous in the GS2Ri1-2 and GS2Ri1-4 populations (Additional file mGM-CSF and OsMYBS2RNAi transgenes were obtained in the F5 populations, which were derived from self-pollination of GS2Ri1-2-1, GS2Ri4-1-2, and GS2Ri4-4-1 plants (Additional file A dihybrid cross was used to produced trangenic rice plants containing both 2 seed population, in which the mGM-CSF and OsMYBS2RNAi transgenes were either homozygous or heterozygous. Therefore, GS2Ri1 and GS2Ri4 cells must contain at least one copy of the mGM-CSF and OsMYBS2RNAi transgenes. To test whether increased dosage of the mGM-CSF and OsMYBS2RNAi transgenes in rice suspension cells can further increase production of rmGM-CSF, homozygous F5 seeds were used to establish suspension cell lines of GS2Ri1-2-1 and GS2Ri4-1-2, both containing two copies of the mGM-CSF and OsMYBS2RNAi transgenes. Western blot analysis and ELISA were used to compare the production of rmGM-CSF with the control cell line G5 and the F3 seed-derived cell line GS2Ri1. The concentration of rmGM-CSF in the culture medium of the GS2Ri1-2-1 and GS2Ri4-1-2 cell lines after sugar depletion for 5 days was 95.6 and 118.8 mg/L, which were 4 and 5.1 times higher than that of the G5 control cell line, respectively (Fig. 5 seed-derived suspension cell cultures.Gene dosage is correlated with expression level and, in the majority of cases, an increase in gene copy number enhances the expression of genes . SuspensαAmy3 promoter and signal peptide. Liu et al. [αAmy3 or CysP by RNAi increased the yield of human GM-CSF recombinant protein by approximately 2.5-fold. [OsMYBS2 gene-silencing strategy. A strategy that combines all previous approaches is expected to further improve recombinant protein production in rice suspension cells. In addition to the αAmy3 promoter, a modified rice αAmy8 promoter has been used to produce a recombinant human epidermal growth factor in rice suspension cells and seedlings [OsMYBS2 expression increases the mRNA level of αAmy8 in rice suspension cells [αAmy8 promoter activity can be expected using an OsMYBS2 gene-silencing strategy.Various strategies have been used to improve recombinant protein productivity in the rice suspension cell culture system based on the u et al. , 43 used.5-fold. , 18. Theeedlings . Knockdoon cells , the proon cells . TherefoαAmy3 promoter. Reduction of OsMYBS2 expression is essential for the strong activation of the αAmy3 promoter in rice suspension cells under conditions of sugar depletion. On this basis, through knockdown of OsMYBS2 expression, αAmy3 promoter activity can be increased, thereby facilitating and accelerating the accumulation of secreted recombinant proteins in rice cell suspension cultures.The function of the rice transcription factor OsMYBS2 underlies the mechanism of sugar regulation of the Additional file 1: Table S1. Genotyping result of seedlings. Fig. S1. Suspension rice cell morphology of the WT, two OsMYBS2RNAi only lines, S2Ri2 and S2Ri6, two mGM-CSF only lines, G3 and G5, and two mGM-CSF/OsMYBS2RNAi lines, GS2Ri1 and GS2Ri4. Fig. S2. Abundance of rmGM-CSF in mGM-CSF/OsMYBS2RNAi transgenic rice suspension cell lines was higher than that in mGM-CSF only transgenic lines. Fig. S3. PCR-based detection of αAmy3::mGM-CSF and Ubi::OsMYBS2RNAi chimeric genes in selected F5 progeny derived from self-pollination of the F4 population.


Background: In general, qualitative research design often involves merging together various data collection strategies, and researcher’s may need to be prepared to spend longer periods in the field to pursue data collection opportunities that were not foreseen. Furthermore, nurse researchers performing qualitative research among patients and their relatives often experience unforeseen ethical dilemmas.This paper aimed to explore aspects of ethical dilemmas related to qualitative nursing research among patients and their relatives in the intensive care unit (ICU).This paper is based on a qualitative researcher’s personal experience during a hermeneutic phenomenological study involving close observation and in-depth interviews with 11 intensive care nurses. Data were collected at two ICUs in two Norwegian university hospitals.The study was approved by the Norwegian Social Science Data Services (NSD). The Regional Committee for Medical and Health Research Ethics (REK) granted dispensation to the project regarding health personnels confidentiality of the patients who were present during the observation (2012/622-4).Close observation with nurses in the ICU requires the researcher to balance being a qualitative researcher, an ICU nurse and a sensitive fellow human being open to the suffering of the other—that is, being embodied, engaged and affected by sensitive situations and simultaneously constantly stepping back and reflecting on the meaning of those situations.The qualitative researcher’s ethical awareness also entails knowing and acknowledging his or her own vulnerability, which becomes apparent in the researcher-participant relationship and settings in which being a fellow human always overrules the researcher’s role in ethical dilemmas. The purpose of this article was to explore aspects of ethical dilemmas related to qualitative nursing research among patients and their relatives in the intensive care unit (ICU). Therefore, a nursing researcher performing field work in a familiar area of nursing must set clear boundaries between oneself, the patients, and their family as well as other staff through a continuous process of reflexivity about the emic and ethic observations and interaction with the informants. Otherwise, these boundaries can become obscured and the role as a nurse researcher can become difficult to uphold.3In general, qualitative research design often involves merging together various data collection strategies, and researchers may need to be prepared to spend longer periods in the field to pursue data collection opportunities that were not foreseen.46 Based on fieldnotes from a hermeneutic phenomenological study, we discuss “ethical dilemmas embedded in the meeting between a researcher, the patient and their relatives when doing fieldwork in the ICU.” Benner et al. and Brinkmann and Kvale argue that particular exemplars of ethically justifiable and ethically questionable research can add depth, nuances, and qualitative distinctions and can contribute to ethical reflections. Furthermore, Brinkmann and Kvale state that examples help researchers evaluate their research practice and point to ethical descriptions of situations as an approach to learning ethical behavior in qualitative research.The motivation for this article is our own experiences both as researchers and nurses. One such method is close observation. According to van Manen, close observation generates different forms of material than those that can be obtained via written or interview approaches. During close observation, the researcher is present when incidents occur: this proximity gives the researcher firsthand knowledge of anecdotes relevant for his or her research project.11 Furthermore, van Manen11 explained that the method of close observation requires that one simultaneously be both a participant and an observer and involves an attitude of assuming a relationship that is as close as possible while retaining a hermeneutic alertness to situations that allow us to constantly step back and reflect on the meaning of these situations.In general, qualitative researchers often combine a complex array of data derived from a variety of sources and use a variety of methods.12 Data were collected through close observations of bedside nursing and in-depth interviews with 11 ICU nurses during a 10-month period spanning from December 2012 to September 2013. Field notes were written in a notebook during the observations, and more detailed descriptions of the observations were recorded immediately after each shift.The empirical basis for our ethical discussion is personal experience as a researcher during a hermeneutic phenomenological study of the phenomenon of becoming aware of signs of incipient changes in patients’ clinical conditions, including both improvement and deterioration. In the ICU, patients can experience discomfort, loss of control, transformations of perception, and surreal experiences.15 The admission of a family member to the ICU in a life-threatening condition places heavy stress and anxiety on a family in addition to the uncertainty and fear involved with potentially losing a family member.17Intensive care patients have life-threatening conditions and require life-sustaining interventions and technological support for survival, which entails continuous monitoring of their vital functions, dynamic interventions, and health-promoting activities.Close observation of intensive care nurses in ICUs implies that patients and their relatives become indirectly involved parties. The Regional Committee for Medical and Health Research Ethics (REK) granted dispensation to the project regarding health personnels’ confidentiality of the patients who were present during the observation period (2012/622-4). Based on recommendations made by the REK, the patients’ relatives received written and oral information about the research project and their right to make requests for close observations on behalf of the patient. In addition, the researcher must understand procedures such as risk and benefit assessments, informed consent, confidentiality, and treatment of vulnerable groups. Clinical research involving critically ill patients is necessary to improve their care and outcomes. However, critically ill patients are often unable to provide informed consent for research due to their illness or treatment.19 Permission to conduct research among critically ill patients may present a dilemma because patients who are eligible to participate in research are often unable to provide consent, and their healthcare proxies are either unavailable or overwhelmed. Thus, researchers have relied on different frameworks to obtain consent in the ICU, most commonly using substitute decision makers.Researchers are guided by ethical principles to protect study participants, and they must ensure that their studies are based on justice, beneficence, and respect for human dignity. presenting a personal description of a lived experience involves describing one’s experience as much as possible in experiential terms while focusing on a particular situation. Furthermore, a personal experience, called a “lived-experience description,” is a description of the experience, as it was, that involves one’s state of mind, including feelings, mood, and emotions.In the following, we present the personal experience of a researcher when performing fieldwork with nurses in the ICU. According to van Manen,It is morning, and I [researcher] am together with Jenny [the nurse], who is caring for an adult mechanically ventilated patient with a serious condition who is in a life-threatening situation.When I enter the ICU room, I feel overwhelmed. There are three patients in the room, three patients with different disorders, and each of them seems to be in the same bad condition. Monitors, infusion pumps, ventilators, and dialysis machines are scattered around the patient’s bed, each of which generates a high sound level. Alarms frequently indicate that something is wrong and must be adjusted. I can hear the rhythmic sound of the ventilator as an ongoing hum. There are many healthcare workers in the ICU room, and I can see 1–2 nurses at the bedside of each of the three patients.I did not make these observations right away, so I have to do them after the situation is calm…I think it is important that I know what I have in terms of initial observations so that I have something to relate it to if changes occur, and changes do normally occur.In the visiting hour, the patient’s father comes to the ICU. I can see in his body language that the patient’s serious and unstable condition places heavy stress and anxiety on him. He is tense in his body, pale in the face, tears tremble, and I can see desperation in his eyes. I feel so sorry for him and it simply got under my skin, and it is difficult to focus on the work of Jenny.Jenny’s priority immediately after the report from the night shift is to start morning care. I am assisting Jenny in morning care of the patient, and I can see that she is working in a concentrated and systematic manner at the bedside. Morning care is a bit split up because she [the patient] is so unstable and demanding in connection with oral hygiene. I can see that Jenny has a worried expression on her face, and she often stops and asks, “What happens now?” Jenny did not get a thorough-enough initial observation of the patient and says,The patient’s father addressed me as a nurse with questions about the patient’s condition, treatment plan, and prognosis in the same manner that he addressed Jenny. I experience that as an ethical dilemma, and I feel that it is difficult to balance being an ICU nurse with limited competence and at the same time not dismiss the patient’s father’s appeals for help. I place my hand on his shoulder and say, “I can understand that you have a lot of questions, and I will tell the ICU nurse so that she can inform you.” I can see in his eyes that he is insecure, and I am thinking that he may perceive that I know something I don’t want to tell him.I feel that I need to keep my distance and feel that it is far too much for me, and I feel vulnerable and overwhelmed by my own feelings. I agree with Jenny that I will go to a quiet place outside the ICU and write field notes in a notebook based on what I sense  and emotions.When I am back, I continue to assist Jenny in nursing care during the shift, for example, oral hygiene, changing the position in bed, and tracheal suction. At the end of the shift, the patient’s condition is more stable, and the situation is more calm .In the close observation of Jenny, I encountered a situation that affected me as a researcher, an ICU nurse and a human being. I was touched and moved by meeting both a patient who was in a critical and life-threatening situation and her father.It was also a balancing act between assisting Jenny in nursing care within the limits of my competence [as an ICU nurse] and what was ethical for me as a researcher to participate in. I also wondered how that affected the observations.11 including thematic reflections. Thematic reflection refers to the process of recovering structures of meaning that are embodied in the researcher’s experience, as represented in text. Grasping and formulating a thematic understanding is a complex and creative process; it is not a rule-bound process but is instead a free act of “seeing” meaning.The analyses of the fieldnote were performed using the reflective methods of van Manen− Being a qualitative researcher, an ICU nurse, and a fellow human being open to the suffering of the other.− Being a participant and at the same time an observer; being embodied, engaged, and affected by sensitive situations and simultaneously constantly stepping back and reflecting on the meaning of those situations.The personal experience of the researcher describes the following aspects of ethical dilemmas experienced when performing fieldwork with nurses in the ICU:These findings led us to the phenomenology of sensation of the Danish philosopher Knud Ejler Løgstrup, the thinking of the Norwegian nurse and philosopher Kari Martinsen and the thinking of Løgstrup in a clinical nursing context. Their perspectives were used to reflect on the themes with the goal of arriving at a comprehensive understanding of the researcher’s experience when performing fieldwork with nurses in the ICU. Martinsen explains that when nurses in a clinical context are sensitive and attentive, they are receptive, touched, and moved to respond to the unique patient’s appeal and needs.The personal description reflects ethical dilemmas and demonstrates the challenge of carefully balancing being a qualitative researcher, an intensive care nurse, and a fellow human being and witnessing the suffering of the other. Patient vulnerability is a key concept in nursing, and protecting the patient from harm is a fundamental part of the role of nurses.24 Sellman defines the vulnerability of severely ill patients’ vulnerability using the term “more-than-ordinary.” Furthermore, for unconscious patients in the ICU, nurses’ competence to provide care depends on the nurses’ capacity to recognize the specific and general vulnerability of a given individual and to act in suitably protective ways. In relation to the personal description, the researcher’s sensitivity when meeting the patient and her father was a core nursing attribute. The researcher tried to understand their situation and not dismiss the patient’s father’s appeals for help. Purdy explains that the essence of being vulnerable is openness to circumstances and the foundation of being influenced. In relation to the personal description, this statement means that in close observation of ICU nurses, the researcher, who was also an experienced ICU nurse, was touched and moved by interacting with both the critically ill patient in a life-threatening situation and her father. During the moments of openness and attentiveness described in the experience description, the researcher may have been vulnerable. This observation is similar to that of Angel and Vatne, who explain that nurses’ vulnerability lies in their engagement in caring for patients. This observation may also be congruent with the findings of Angel and Vatne, who demonstrated that by being open and sensitive to patients and their needs, nurses may experience their own sense of vulnerability, which may manifest in feelings of being out of control and overwhelmed by emotions. The researcher in the personal description was open to the suffering of the patient and her father and was sensitive to what they expressed through their bodies. The researcher felt overwhelmed by the situation and her own strong emotions and caused emotions of unease in others; thus, the researcher found it difficult to focus on the work of Jenny.People who are or who become recipients of healthcare in general and nursing care in particular can be considered vulnerable. In the context of nursing practice, patients are not always able to either make judgments about self-protective actions or to know when they are being exploited. explain that the researcher’s ethical awareness also entails knowing and acknowledging his or her vulnerability, which becomes apparent in the researcher–participant relationship. In difficult interview settings, being a human always overrules the researcher role in ethical dilemmas. In relation to the personal description, this may mean that although a situation is meaningful from a research perspective, a researcher leaves when she or he interprets her presence as burdensome for the nurse, the patient, and the patient’s relatives. In this particular experience, the researcher felt that it was not ethical to participate in the situation when the patient’s father was visiting the patient. The researcher sensed that the father became uneasy because of her presence and considered that the right thing to do was to leave the ICU room. This observation may be similar to the findings of Clancy, in which the researchers are reminded of the vulnerability of all persons in the research project and give rise to legitimate questions such as “Is my presence here right now justified?” even though issues of informed consent have been addressed.Haahr et al. explains that the mind is in sensation, always touched and moved by the situation, and that to receive an impression is to be sensitively moved. In relation to the researchers’ personal experience, this statement means that the researcher is receptive to the suffering of the other such as through eye contact, facial expression, body movement, and anxiety. The researcher felt the suffering of the patient and her father in such a strong way that the researcher became affected by it and felt vulnerable. This is similar to the findings of Thorup et al., who demonstrated that vulnerability and suffering have been proven to be sensitive issues for nurses, like a sore point that either serves as an eye-opener by contributing to a deeper understanding of the patients’ vulnerability or causes the development of blind spots.Martinsen11 In relation to the personal description, this statement means that the researcher participated in nursing care and at the same time closely observed Jenny’s everyday practices and interactions with the patient; thus, the researcher was embodied, engaged, and affected by sensitive situations and at the same time constantly stepping back and reflecting on the meaning of those situations.The method of close observation requires that one simultaneously is a participant and an observer. explains that our understanding of other humans is an understanding of impressions of them and not their characteristics. This impression gives us access to them, and mimicry, gestures, tone, and body posture play a crucial role. Similarly, Van der Meide et al. explain that both articulated speech and nonarticulated speech—body language—are considered valid ways of expressing meaning.Close observation enabled the researcher to focus on the meaning expressed by an individual nurse’s entire body, such as gestures, facial expressions, and posture, which changed with changes in the patient’s condition. If the patient’s condition became unstable or unclear, Jenny moved closer to the patient’s bedside and started to examine the patient using her senses  and by monitoring. Løgstrup who demonstrated that the role as a researcher when performing field observations was a continuous balance between intimacy and distance, being personally engaged, preserving dignity and confidence, and at the same time maintaining an analytic distance. Løgstrup explained that without distance, we would be lost in sensation and unable to understand the situation. The researcher in the experience description was engaged and affected by sensitive situations during the shift and wondered how this could have affected the observation. The situation was overwhelming, and the researcher felt the need to maintain distance to focus on observing the nurse. Martinsen explained the notion of life interpretation (tydning) as a way for nurses to be present in a situation. Clarification requires nurses to be receptive, attuned, and attentively present in encounters with patients and not to remain outside what should be clarified. Clarification involves being in the shifting interplay between sensation and understanding, searching for words that may help to clarify meanings in impressions. The researcher created distance by “taking a step back” to a quiet place outside the ICU and thus attempted to understand what was sensed in relation to the unique situation. Løgstrup35 explained that understanding creates both distance between the sensed and the sensing and an open space in which to move and think.In practice, this means that close observation involves a balancing act, that is, drawing as close as possible to Jenny’s way of being and experiences, including the situations and settings in which she is involved, while distancing or retaining a hermeneutic alertness as an ongoing process in which the researcher takes a step back and reflects on the meaning of various situations and episodes. This is similar to Høgh et al.,36 stated that with language, understanding creates distance between the sensed and the sensing and creates an open space in which to move and think. In this space, which Løgstrup36 calls “the fictive space of understanding,” sensation reaches into understanding and makes it intuitive.Emotions and thoughts that were evoked by what the researcher sensed during the observation were written in a notebook which enabled meaningful insights. LøgstrupEthical dilemmas when conducting close observation with nurses in the ICU are far more complex than the researcher might anticipate.Close observation with nurses in the ICU requires the researcher to balance being a qualitative researcher, an ICU nurse, and a sensitive fellow human being open to the suffering of the other—that is, being simultaneously a participant and an observer.The qualitative researcher’s ethical awareness also entails knowing and acknowledging his or her own vulnerability, which becomes apparent in the researcher–participant relationship and settings in which being a fellow human always overrules the researcher’s role in ethical dilemmas.Knowledge about how to act ethically when conducting qualitative nursing research among vulnerable patients and settings is a subject for future research education in relation to ethical matters.


Median tumor size was 12 cm (range 3–20 cm). Median estimated blood loss was 300 (range 150–1000) cc. One patient was still alive at last follow-up (4 months), and in total, eight patients have died with a median time-to-death of 12 months (range 10 days–24 months). RNATT using TB maneuvers like liver mobilization and pancreas-spleen en bloc mobilization provide excellent exposure to the retroperitoneal space and enable the safe removal of UTUC with venous TT.Upper urinary tract urothelial cell carcinoma (UTUC) with venous tumor thrombus (TT) that extends into the renal vein (RV) and inferior vena cava (IVC) is a rare entity and its management is a surgical challenge. We report the largest single experience of surgical management of UTUC and accompanying venous TT with radical nephroureterectomy and tumor thrombectomy (RNATT) using transplant-based (TB) surgical techniques. From September 2003 to June 2021, nine patients with UTUC and venous TT underwent RNATT. Demographics, disease characteristics, surgical details, 30-day postoperative complications, and overall survival (OS) were analyzed. All nine patients had extension of the TT into the RV. Of those, seven had additional extension of the TT into the IVC. Venous TT level was categorized as 0 ( Renal cell carcinoma (RCC) is the most common malignancy that results in venous tumor thrombus (TT) and is associated with vascular extension into the inferior vena cava (IVC) in 4–10% of cases . In a laHerein, we describe the results for nine cases of UTUC and venous TT managed with radical nephroureterectomy and tumor thrombectomy (RNATT) using transplant-based (TB) surgical techniques. These methods aid in achieving safe resection of large urological tumors with venous TT, reducing blood loss and blood transfusion requirements by providing adequate exposure and vascular control of the IVC ,7,8.From September 2003 to June 2021, nine patients with UTUC and accompanying venous TT underwent RNATT at our institution. The study of these patients was in accordance with our University of Miami Institutional Review Board  and the Helsinki Declaration (as revised in 2013). Informed consent was given, including the risks associated with the complexity of the surgery, such as bleeding and tumor embolization into the pulmonary arteries.Initial diagnosis was made using computed tomography (CT) . CardiacTransesophageal echocardiography (TEE) was used in all patients, as it is considered to be an essential part of their surgical management. TEE is used in both delineating the cranial extent of the TT and in identifying/ruling out the existence of pulmonary emboli before, during, and after surgery . Overall survival (OS) was ascertained by a review of the patient’s medical record or the Social Security Death Index (SSDI) database when necessary .This TB surgical technique for resection of RCC and UTUC with tumor thrombus has been described at length previously and is illustrated in We pursued early intraoperative ligation of the involved renal artery, which decompresses collateral circulation, decreases blood loss, and prevents the need for blood transfusions . With thIn some cases, exposure of a right UTUC required liver mobilization ,8,10,13.In this fashion, the infrahepatic and retrohepatic portions of the IVC are completely exposed (level IIIa TT). In addition to mobilizing the liver off the cava, creating a plane between the IVC and the posterior abdominal wall was also important because it permitted circumferential vascular control of the cava in case of the need to perform the reconstruction or the removal of the IVC. In addition, small tributaries can become engorged to look like lumbar vessels, and they need to be identified and ligated. The infrarenal cava was controlled and a vascular clamp was placed across the retrohepatic IVC below the major hepatic veins (level IIIa TT). The right adrenal and RV were clamped for the left UTUC. The IVC was incised, and the tumor was sharply dissected off the IVC. Following removal of the tumor thrombus, the IVC was sutured closed. The rest of the involved ureter was removed along with the kidney.2) or carboplatin (if glomerular filtration rate < 50 mL/min) administered intravenously on day 1, and gemcitabine (1000 mg/m2) administered intravenously on days 1 and 8. Chemotherapy was initiated within 90 days of surgery; none of the patients included in this series received neoadjuvant chemotherapy. Chemotherapy was administered according to the following schedule: four 21-day cycles of chemotherapy with either cisplatin , I (n = 2), II (n = 4), and IIIa (n = 1). Median tumor size was 12 cm (range 3–20 cm). Median estimated blood loss was 300 (range 150–1000) cc. Four patients required a blood transfusion. Median requirement of packed red blood cells was 0 (range 0–7) U during surgery. The median postoperative creatinine was 1.0 mg/dL (range 0.6–1.4 mg/dL). The median length of hospital stay was 8 (range 6–28) days. Median age was 72 (range 59–82) years, and six of the patients were female. All nine patients had extension of TT into the RV. Of those, seven had additional extension of the TT into the IVC. None of the patients had TT extending into the right atrium. The IVC TT level was classified as 0  graft and the insertion of an IVC filter  Figure A. AnotheThree of these patients received adjuvant chemotherapy. Three other patients who were being followed by an oncologist did not receive chemotherapy due to advanced age (range: 72–82 years). In total, eight of the nine patients have died. Median survival was 12 months (range: 10 days–24 months); only one patient was still alive at last follow-up (4 months).Patients with invasive UTUC do not constitute a substantial portion of cancer cases and their treatment can be very complicated. A review of the MD Anderson Cancer Center’s experience found that there has been minimal improvement in disease-specific survival of UTUC, calling for a change in treatment regimen . AlthougAlthough the surgical procedure for patients presenting with invasive or metastatic UTUC is high-risk and challenging, it has several advantages. One is that it provides better and more accurate staging than the combination URS biopsy/cross-sectional imaging, thus paving the way for further treatment decision-making . It decrThis current study is the largest series of UTUC with TT resected safely and without the use of large amounts of blood products due to the early ligation of the renal artery. Two of these nine cases had a complex IVC reconstruction. One patient had an interposition ringed Gortex graft with an IVC filter , and theOur experience affirms the safe use of liver transplantation techniques for the resection of UTUC tumors with TT extending into the IVC. Clearly, this approach facilitates the resection of large UTUC tumors by increasing the exposure of the retroperitoneal space. The concept of resorting to an entirely intra-abdominal approach without the need (in most cases) for cardiopulmonary or veno-venous bypass is an additional byproduct of this approach ,5,8, as Neoadjuvant and adjuvant chemotherapy before or after radical nephroureterectomy (RNU) has been used to improve the prognosis of UTUC; however, the evidence remains mixed on their efficacy . NeoadjuThere is no doubt that our cases are locally advanced metastatic cases according to cross-sectional preoperative imaging. In this way, we would not overtreat the patient if this would have been our therapeutic schedule choice, and we would obtain better margins and theoretically better oncological outcomes. On the contrary, the surgery should not be delayed. The time frame until surgery in our cases of metastatic UTUC is crucial to avoid the potential catastrophe of the thrombus extending upwards through the IVC and right atrium, making surgery more difficult or even impossible. The most common therapeutic schedule is cisplatin–gemcitabine  in patients with normal GFR or carboplatin  if GFR is proved decreased. Patients unfit for chemotherapy  will not receive additional treatment after surgery, but they will still have the benefit for palliation and symptoms relief .Despite aggressive surgical treatment, the prognosis of these patients is very grim, with reported survival being between 6 months and 14 months ,29. HubeThe main limitation of this study could be represented by the potentially low reproducibility of this procedure among the entire urological community. As the surgical management of UTUC with tumor thrombus is very complex, treatment should be decided within a multidisciplinary consensus.TB approaches that utilize liver, pancreas-spleen, and IVC mobilization techniques help to achieve a good exposure of the retroperitoneal space and excellent control of the IVC for the safe resection of UTUC with venous TT; however, disease-specific survival is still poor in these patients.


Classical swine fever (CSF) is considered one of the most important diseases of swine because of the far-reaching economic impact the disease causes to affected countries and regions. The state of Mato Grosso (MT) is part of Brazil's CSF-free zone. CSF status is uncertain in some of MT's neighboring States and countries, which has resulted in the perception that MT is at high risk for the disease. However, the risk for CSF introduction into MT has not been previously assessed. Here, we estimated that the risk for CSF introduction into the MT is highly heterogeneous. The risk associated with shipment of commercial pigs was concentrated in specific municipalities with intense commercial pig production, whereas the risk associated with movement of wild boars was clustered in certain municipalities located close to the state's borders, mostly in northern and southwestern MT. Considering the two pathways of possible introduction assessed here, these results demonstrate the importance of using alternative strategies for surveillance that target different routes and account for different likelihoods of introduction. These results will help to design, implement, and monitor surveillance activities for sustaining the CSF-free status of MT at times when Brazil plans to expand the recognition of disease-free status for other regions in the country. Pestivirus of the family Flaviviridae referred to as CSF virus (CSFv). The most common routes for CSF spread include oronasal transmission through direct or indirect contact with infected pigs, consumption of pig meat infected with the virus, and vertical transmission from an infected sow to her offspring , also referred to as hog cholera, is arguably one of the most important viral diseases affecting domestic and wild swine, and for that reason, the disease is notifiable to the World Animal Health Organization (OIE). The CSF's impact on the swine industry is associated with the mortality and reduction of productivity caused by the disease, and, most importantly, with disease-related trade restrictions, which results in important economic and social consequences for infected areas –3. CSF iffspring –6.n = 1,933,248 pigs, 74.6%) of MT's pig population is concentrated at 1.3% (n = 550) of the premises registered as commercial pig farms in the state, whereas the remaining 657,624 (25.4%) pigs are located in 43,398 backyard (subsistence) farms  of the 27 administrative units of Brazil have been recognized by the OIE as CSF-free since May 2016; those 16 administrative units constitute the majority of the country's national pig production. The state of Mato Grosso (MT) is the fifth largest pig producer in the country, with 2,590,872 heads corresponding to approximately 8.7% of the Brazilian pig herd and is located in the CSF-free zone of Brazil. Most  such as CSF, African swine fever (ASF), and foot-and-mouth disease (FMD). Many studies have been developed to assess the risk of introduction of these diseases into free areas, mostly through movement of live animals or animal products as part of international trade, which is one of the reasons for performing risk assessments according to the OIE. In the early 2000s, most published risk assessments were related to FMD and CSF and considered pathways such as pig movement, pig products , and fomites –12. AfteThe objective of the study here was to rank MT municipalities in terms of their risk for CSFv introduction, either through wild boar movements or through legal movement of commercial pigs, and to compare those ranks to evaluate the correlation at the municipality-level risk of entry through those two pathways. The results will help to inform the design of surveillance strategies and allocation of resources in MT with the ultimate objective of preventing or early detection of a hypothetical introduction of CSFv into the State.The risk for CSFv introduction into MT through two alternative pathways, namely, (i) the movement of live pigs assuming a hypothetical CSF outbreak in the CSF-free zone of Brazil and (ii) free ranging of wild boars, described in the following sections, was assessed at the state and municipality levels in MT. Municipalities were subsequently ranked in terms of the risk associated with each pathway, and ranks were compared to evaluate the correlation between pathways.Official data from MT's Official Veterinary Service (INDEA/MT) regarding the legal movement of pigs into MT from 2016 through 2018 were used . All shivia movement of live pigs during a 1-year time period, which was assessed both at the state and municipality levels. For the estimate of risk at the state level, we considered the total number of pigs that were shipped to MT from the states that are part of the CSF-free zone and, hence, allowed to trade with MT, given the hypothetical scenario of one undetected epidemic on the CSF-free zone of Brazil. For the probability of introducing the disease into any municipality of MT, we considered the number of animals that were shipped into each municipality of MT. The annual risk for CSF introduction into MT farms through pig movements (Rpm) was quantified assuming a binomial model of the formA stochastic risk assessment model was fitted to estimate the probability of introduction of CSFv into MT sm is the number of pigs shipped from the CSF-free zone into each municipality m of MT before detection of the outbreak in the free zone; for the estimates at the state level, the total number of pigs shipped into MT was used. Psm was the probability of introduction of one infected animal. The value of Psm was the same for each municipality m and for the state of MT, and it was computed as the product of four conditional probabilities (P1–P4) describing the nodes of the risk pathway, which were modeled in a scenario tree .” The calculation of these parameters is described later in this section.The first node (P1) of the scenario tree  was the The second and third nodes, denoted as P2 and P3, were the probabilities that the infected pig survived infection and shipment, respectively, for which we used a Pert distribution parameterized with data extracted from the literature .m. This probability was calculated as 1 – Pq * Pd, where Pq is the probability of quarantining the animal at the destination, and Pd is the probability of detecting the disease during that quarantine (The last node of the scenario tree (P4) represented the probability that an infected imported pig established contact with a susceptible pig in a farm in MT, causing a CSF outbreak, i.e., assuming a failure of quarantine and detection by OVS at the municipality of destination arantine , 23.population of commercial pigs in free zone (NT)” variable, we used a normal distribution , considering as mean (μ) the total number of pigs in commercial pig farms at the CSF-free zone in 2017, except MT, and σ is the standard deviation of the total number of commercial pigs at the CSF-free zone during the period 2014–2017. This input was one of the components used to calculate P1. Data required to estimate the parameter NT was obtained from the Brazilian Ministry of Agriculture, Livestock and Food Supply (MAPA/BR)  .total number of commercial farms - herd number (NH)” variable were calculated using a normal distribution , considering as mean (μ) the total number of commercial pig farms at the CSF-free zone in 2017, and σ is the standard deviation of the total number of commercial pig farms in the period 2014–2017. This input was used to calculate the average herd size (H). Data required to estimate the parameter NH were obtained from the Brazilian Ministry of Agriculture, Livestock and Food Supply (MAPA/BR)  .Number of pigs, expected to be infected in the free-zone before the detection of the outbreak (NI)” was calculated by the equation IP * H * EO, where intraherd prevalence (IP), the average herd size in the CSF-free zone (H), and the number of expected undetected outbreaks at the origin (EO) were multiplied to generate the number of pigs expected to be infected at the CSF-free zone during an outbreak in the silent phase (NI), that is, before the detection of the index case of CSF by the OVS in the origin (average herd size (H), intraherd prevalence (IP), and expected undetected outbreaks (EO) were calculated as explained in the following paragraphs.The variable “e origin . The parm. The average herd size (H) was approximated as the NT/NH ratio in the CSF-free zone.Because states in the CSF-free zone have the same sanitary status regarding CSF, and they are allowed to trade pigs between them, we assumed the CSF-free zone as one single unit, whereas the risk for introduction of CSF was stratified for each municipality of destination intra-herd prevalence (IP)” was calculated using a Pert distribution; although the incubation period of CSF is generally 4–10 days, under field conditions, CSF is expected to show unspecific symptoms at the beginning of an outbreak, which can delay the detection of infected herds in 2–4 weeks, increasing the intraherd prevalence at the moment of detection by the OVS ” is defined as the number of herds that would be infected by the time when a hypothetical epidemic in the CSF-free zone was detected and pig movements into MT banned. EO was assumed to follow a Pert distribution with a minimum of one undetected outbreak (the index case), and the most likely and maximum equal to the number of herds that were affected before the detection of the CSF epidemics in Spain in 2001, and in The Netherlands in 1997, respectively (The “ectively .time-to-detection (Td), i.e., the length in days before the epidemic is detected, and movements into MT are banned. Under field conditions, the detection is expected to take longer than the incubation period. A Pert distribution was used for modeling Td, with the minimum, most likely, and maximum values being those reported in Colombia, in Ceará (a state of Brazil in the CSF non-free zone in which outbreaks occurred in 2018), and the recommendation of the European Union on the parameter that should be used when there is no information available, respectively  and standard deviation (σ) of the total number of pigs that were sent to each municipality m from states of origin s, during this period  was subsequently computed for MT and for each municipality m as the number of pigs shipped per day (n/365) multiplied by the time-of-detection (in days) of an outbreak in the CSF-free zone (Td), so that:The number of pigs that were shipped from the CSF-free zone was estimated considering the number of pigs that came from states s period . Then, tn. The median was the measure of central tendency, and Q1 and Q3 were measures of dispersion. We systematically calculated the final risk probability with different situations for each parameter at a time when the others were kept fixed in the median (second quartile) as the central tendency.A spider graph was generated in Excel to evaluate what parameters  mostly cThe stochastic model was implemented in the @Risk 8.0 software  and run Pig farms registered in the INDEA/MT database by July 2019 were retrieved, including data on type of farms , their geographic location, and the total number of pigs per farm .via wild boars and explained in detail in the following section Analytical Framework.Additionally, data regarding active surveillance activities for CSF in MT pig farms from 2016 to 2018 were retrieved to determine the presence or absence of free-range wild boars at those premises. Records of visits were organized in a dataset, and records repeated on any given farm were removed manually. Presence of wild boars was reported in 1,688 24.7%) of the 6,827 visited farms % of the . Briefly2 and dichotomized using the median value . The number of commercial pigs in the municipality was included in the computation, in addition to backyard pigs, to account for the probability of contact between backyard pigs and commercial pigs, and because backyard farming was specifically included as a separate variable, thus, accounting for that factors in the computations (2) of each correspondent municipality of MT, and dichotomized using 5 habitants/km2 as the threshold ; the 5 habitants/km threshold was set up because it was the approximate midpoint between the median (2.29 habitants/km2) and mean (6.76 habitants/km2) densities and that resulted on an acceptable 1:3 ratio for the classification of districts as high or low density—alternatively, the use of the mean and median as cutoff values for the classification did not affect the results of the regression model (data non shown). Human density was included as a proxy for the movement of people (tourists or workers) that can carry contaminated food that can be disposed and accessed by wild boars (n = 10) representing different epidemiological conditions. International experts, which were chosen by snowball sampling technique after consultation with the OIE reference laboratories for ASF in Spain, the UK, and the National Reference Laboratory of the Russian Federation, were requested to rank the 10 hypothetical scenarios in terms of their likelihood of serving as a port of entry for ASF into the country, where 1 meant the lowest risk, and 10 meant the highest risk for introduction of the disease in districts of a free country, and the hypothetical scenarios were categorized by a combination of dichotomized  risk factors listed before. An ordinal logistic regression model was fitted to estimate the relative weight that the experts implicitly gave to each of the variables , as approximated by the value of the regression coefficients. A risk score of the introduction of CSF through wild boar (Rbm) was subsequently computed assuming an increase by factors of Rbm = β0 + 3.39 * pig density + 4.16 * backyard farming share + 0.55 * human density + 0.67 * road density + 3.4 * wild boar density + 2.34 * share border with non-CSF-free region for municipalities categorized as high (or yes), compared with those categorized as low (or no). Rbm was computed for each of the 141 municipalities in MT as the sum of the dichotomized values of the risk predictors weighted by an increase in risk assumed for each of the factors. Finally, municipalities were ranked in terms of the computed value of Rbm.The assumption here was that wild boars in Bolivia and in Brazilian states outside of the CSF-free zone may carry the CSFv and pass freely through the MT borders. We also assumed that the risk at the municipality level would be influenced by the domestic pig density, wild boar density, backyard farming share, shared border with CSF-infected zone or Bolivia, road density, and human population density in the state. The values of those variables were dichotomized (high/low or yes/no). Specifically, (a) pig density was calculated as the number of pigs in each municipality divided by the area in kmutations . (b) Bacutations . Values utations . (c) Humutations  for eachld boars , 39–41. ld boars . (e) Willd boars . DichotoThe MaxEnt software  was useds) asThe correlation between the two pathways for the risk of introduction of CSF into MT was computed using a Spearman correlation test , Si is the rank for the value yi, which is the risk score generated by the assessment for the introduction of CSFv through movement of wild boars (Rbm), and n is the number of observations, i.e., the number of municipalities in MT (n = 141). The correlation was implemented in the RStudio Team , or none of the pathways.n = 89, 63.1%) municipalities (n), respectively  was heavily concentrated, with five (3.5%) municipalities accounting for 96% of the total risk and much of the risk clustered in the central districts of MT . The risectively .The maximum entropy algorithm calculated the distribution of the wild boar population in MT using 1,048 observations of wild boar as a training data and 261 observations as a testing data from the total of 1,688 observations captured from active surveillance performed by OVS of MT from 2016 to 2018. Observations, 379, were excluded from the model due to issues with the geographic coordinates collected during the surveillance activity. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was 0.765 for testing, with 0.014 of standard deviation, which was considered an acceptable accuracy. Although wild boars were predicted to be distributed throughout the state , most ofvia movement of domestic pigs was poorly correlated  with the risk associated with free roaming of wild boars. Only five municipalities  were estimated at highest risk for introduction of CSF into MT through both pathways , indicating that the districts estimated at highest risk for a given pathway were not at highest risk for the other route. However, because the risk for these two pathways was calculated using different methods, the raw values are not comparable. This finding is consistent with the need for enforcing different policy for districts regarding the design of surveillance and early detection strategies to prioritize practices associated with the routes that impose the highest risk to the municipality.The legislation that MT follows regarding CSF surveillance is dictated by the Brazilian Federal government, by which active serological surveillance is conducted only biannually in random backyard pig farms and in commercial farms only on months when the mortality rate exceeds the threshold for different ages or categories . Howevervia legal import of pigs and pig products, and the highest values for the probability of introduction were concentrated in three US states traditionally associated with pig production  highly influences the risk. Because Td is expected to be the same for all municipalities, the variability of Td is not expected to affect the ranks estimated here. However, because the variability of Td may affect the likelihood of an outbreak, the sensitivity of results to the variability of the parameter contributes to highlighting the importance of coordination and collaboration between districts in Brazil, and the impact that early detection has in the mitigation of the impact of epidemics.Although certain municipalities at the borders were found at highest risk for the introduction through wild boars , we found that certain municipalities at the central region of MT were also at high risk, likely because of the combination of a number of factors, such as high density of humans and pigs and the presence of wild boars that would increase risk. The model used for the calculation of the risk in this pathway may outweigh the lack of a shared border with CSF-free areas, and the model did not require a shared border with CSF-free areas to have a negligible risk from this pathway. Certainly, some believe that the biggest challenge in maintaining a free or controlled area for CSF is for the OVS to be able to enforce control and eradication measures on subsistence pig farms . In thosEpidemic models have been increasingly used to evaluate and inform disease surveillance and control policies. For that reason, risk assessments are important tools that should be routinely incorporated by OVSs to support the design of risk-based surveillance activities . QuantitIn conclusion, results here indicate that the risk for introduction of CSF into MT is spatially heterogeneous, suggesting that different approaches of targeted surveillance should be implemented in the state considering, at least, two primary objectives. On one hand, there is a need for increasing the number of OVS visits to commercial farms that receive animals from outside the state, inspecting and quarantining pigs as soon as they arrive at the farm, and considering the design of passive surveillance activities targeting the early detection of CSF-like signs in those particular farms and municipalities. On the other hand, for districts in which risk was mostly associated with wild boars, actions like sampling hunted wild boars and implementation of surveillance and educational and outreach programs in backyard farms should be prioritized . ResultsThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.DS led the data collection and analysis and wrote much of the paper. FK collaborated with the data analysis process and wrote some of the paper. AP supervised the design of the study, paper, and the data analysis process and wrote much of the paper. 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.