The WHO definition of trachomatous trichiasis (TT) is “at least one eyelash touching the globe, or evidence of recent epilation of in-turned eyelashes”, reflecting the fact that epilation is used as a self-management tool for TT. In Fiji’s Western Division, a high TT prevalence (8.7% in those aged ≥15 years) was reported in a 2012 survey, yet a 2013 survey found no TT and Fijian ophthalmologists rarely see TT cases. Local anecdote suggests that eyelash epilation is a common behaviour, even in the absence of trichiasis. Epilators may have been identified as TT cases in previous surveys.We used a preliminary focus group to design an interview questionnaire, and subsequently conducted a population-based prevalence survey to estimate the prevalence of epilation in the absence of trichiasis, and factors associated with this behaviour, in the Western Division of Fiji.We sampled 695 individuals aged ≥15 years from a total of 457 households in 23 villages. 125 participants (18%) reported epilating their eyelashes at least once within the past year. Photographs were obtained of the eyes of 121/125 (97%) individuals who epilated, and subsequent analysis by an experienced trachoma grader found no cases of trachomatous conjunctival scarring or trichiasis. The age- and sex- adjusted prevalence of epilation in those aged ≥15 years was 8.6% (95% CI 5.7–11.3%). iTaukei ethnicity, female gender, and a higher frequency of drinking kava root were independently associated with epilation.Epilation occurs in this population in the absence of trichiasis, with sufficient frequency to have markedly inflated previous estimates of local TT prevalence. Individuals with epilated eyelashes should be confirmed as having epilated in-turned eyelashes in an eye with scarring of the conjunctiva before being counted as cases of TT. Chlamydia trachomatis, represents a major public health issue, and is targeted for global elimination as a public health problem by the year 2020. Until recently, data on trachoma in the Pacific Island states have been sparse, with marked variability in the findings of surveys. The most recent studies in Fiji’s Western Division were conflicted in their estimates of the prevalence of the advanced, blinding, stage of the disease known as trachomatous trichiasis or “TT”. TT results from repeated bouts of infection and resolution, leading to scarring of the eyelid tissue, which causes in-turning of the eyelashes in some individuals so that they grow to touch the globe of the eye. In populations without ready access to healthcare services, individuals may try to self-manage TT by epilating their eyelashes, so that the classical trichiasis sign of contact between eyelashes and eyeball is not seen in surveys. Therefore, the World Health Organization (WHO) definition of TT includes “evidence of recent epilation of in-turned eyelashes”. In the Western Division of Fiji, we carried out a population-based prevalence survey to estimate the prevalence of this behaviour, and to examine associated risk factors. The estimated population prevalence of epilation was 8.6% of those aged ≥15 years, consistent with previously reported estimates of TT in this population, and, importantly, was not associated with any other evidence of advanced trachoma. These data suggest that eyelash epilation is common here, and could inflate estimates of TT wherever such a custom is common. In trachoma surveys, trachomatous scarring should be confirmed to be present when reporting the presence of TT.Trachoma, caused by infection with ocular strains of  Chlamydia trachomatis infection and resolution during childhood, resulting in the gradual accumulation of trachomatous conjunctival scarring (TS). Scarring may progress to distortion of the eyelid and in-turning of the eyelashes to the point that they touch the eyeball . Abrasion of the cornea can lead to opacity and blindness. The village where the focus group occurred was considered by residents to be of wholly iTaukei Fijian ethnicity. No participants were found to have any sign of trachoma on clinical examination.The points discussed during the session fell into 4 themes: motivation for epilation, perceived predispositions to eye symptoms, the Fijian eyecare culture, and a description of the epilation process. The themes and categories derived from the data are shown in Several themes were identified as perceived motivations for eyelash epilation. In each case, transcript extracts have been provided to support the extracted theme. The most commonly cited symptom that could be relieved by epilation was itchiness.“When it’s itchy, I’ll start pulling the hair out”.The group felt that eyelashes targeted for epilation were abnormal, being short and sharp and able to be removed painlessly.“the eyelashes that we pull out, they are different from the normal one.”“they are prickly. It’s only seen from pigs, swines, they have straight, short, sharp eyelashes”.The group described a traditional method of “threading” using fibres from coconut husks, the technique for which was demonstrated during the discussion.“They use a coconut husk like that (demonstrates)”“And they don’t use the pluckers (tweezers)”Occasionally people would take out large numbers of eyelashes at one time:“I pulled out about 120 from my eyes, both of them, with the small ones. Only that was the first time I did that”Some participants felt that epilation was a habit, but others felt it was more a routine part of their culture.“We check our eyes after two, three months…, then when you start with it, then it does become a habit”“it’s a habit, once you start you can’t stop so you try to get it out every time”The participants described good access to and engagement with healthcare services through pharmacists or hospitals when deemed appropriate.“we’re educated now, we’re trying to go to the hospitals. Before they did not go to the hospitals.”Participants described eyecare home remedies and long-held practices“actually that was our old people that has been sent from this generation to that generation downwards. It has been, from that time till now we do that for pain relief”“In some villages we Fijians, we use herbs. If someone has an eye problem or so he gets these and then we just drop them into the eye and then off they go”.Participants believed epilation-inducing symptoms could be precipitated by occupational exposures, such as sunlight and dust.“(it can be brought on by) not using safety goggles and working out in the hot sun, and then out on the roadside”.Some felt that symptoms were associated with the iTaukei cultural practice of drinking kava, as well as the long nights associated with its consumption“one thing is kava, drinking kava, you have more time drinking of kava and less time sleeping.”The population-based survey was carried out from July-September 2015. 695 participants aged ≥15 years from 457 households in 23 clusters consented to participate. Three clusters could not be reached due to logistical issues at the time of survey. 16 clusters were considered to be of iTaukei ethnicity, 3 clusters were considered Indo-Fijian ethnicity, and 4 clusters did not have a clear majority ethnic group. 512 of 695 (74%) participants were female. 437 (63%) participants were ethnic iTaukei and 235 (34%) participants were ethnic Indo-Fijian. The median age of study participants was 43 years .125 (18%) of the 695 individuals interviewed reported epilating their eyelashes at least once within the past year. The overall sex- and age-adjusted prevalence estimate of epilation behaviour in those aged ≥15 years in the Western Division was 8.6% (95% CI 5.7–11.3%).Of the 125 individuals reporting epilation, 124 (99%) consented to examination and conjunctival photography. In 4 of 124 (3%) consenting participants, one or both eyelids were unable to be everted due to discomfort. On examination, no cases of trichiasis were identified, but one suspected case of TS was identified. On subsequent analysis of conjunctival photographs by two independent trachoma graders, no cases of trichiasis or definite TS were identified, with the one clinically suspected TS case thought to have (at best) equivocal evidence of conjunctival scar . TherefoData on the 125 epilators are shown in Results of the two-level multivariable model are shown in When the reported frequency of kava drinking was considered in the full model, a higher frequency was independently associated with increased odds of being a regular epilator, with those reporting drinking kava daily having odds 4.9 times higher than those who reported drinking kava less than monthly or not at all .Despite being significant on univariable analysis, age was not associated with regular epilation in the final model. Of note, the effect of age was markedly decreased when the frequency of kava drinking was included in the model, suggesting that this was in part explained by an increased frequency of kava drinking in younger participants. Eye itchiness in the preceding week was strongly associated with being an epilator on univariable analysis (OR 4.5 95%CI 2.8–7.1), but was not included in the final model as this was collinear with kava drinking.The effect of the frequency of kava drinking on epilation was not confounded by ethnicity, and there was no evidence of interaction between ethnicity and kava drinking frequency on epilation .2. This may account for the apparent discrepancy between TT prevalence estimates  and the lack of people presenting locally for TT surgery. Two individuals with TT reportedly presented to surgical outreach clinics in Fiji between 2011 and 2013, neither of whom received corrective surgery[We have documented the presence of a common behaviour in Fiji that has not previously been described in the literature. Eyelash epilation in the presence of the distorted eyelid morphology associated with cicatricial trichiasis is a frequent finding in trachoma-endemic populations,20–22. Be surgery.The origin of the epilation behaviour in this population is unclear, though our data help to generate hypotheses and exclude some potential explanations. The most commonly described symptom motivating epilation was itchiness, whereas trichiasis is more commonly associated with painful, watery or purulent eyes, or blepharospasm. NeitherPiper methysticum) is a perennial plant that can be used to prepare a non-alcoholic drink by mixing the ground root and stem bases with water[Drinking of kava, and particularly drinking kava often, was a strong independent risk factor for regular epilation in our population. Kava  of the 125 epilators reported never drinking kava. This supports the idea that in Fijian custom a variety of eye symptoms might be considered to be amenable to epilation, with itchiness from kava drinking being just one. It is possible that epilation in this context could also represent a cultural practice reflective of a time when trichiasis was more common and that this persisted even after trichiasis became rare.As further evidence of a cultural determinant of this behaviour, in the full model, we found that iTaukei individuals had 6.0 times greater odds of being an epilator than those of any other ethnicity. The major ethnic groups in Fiji are iTaukei and Indo-Fijian—both with distinct cultures, practices, beliefs and languages. iTaukei are predominantly Christian and speak an indigenous language, whereas Indo-Fijians are mainly Hindu or Muslim and speak a local variant of Hindi. The overall population of Fiji comprises 56.8% iTaukei and 37.5% Indo-Fijian, with the remainder being a mixture of European, Chinese, Rotuman and other Pacific Islanders.Although its origins are elusive, significant differences are seen between the epilation behaviour described here, and the anticipated behaviour if epilation was related to trichiasis. Both the number of eyelashes removed and the frequency of epilation found in this population are noticeably different from those normally reported in the context of TT. A study in Ethiopia, for example, found that among individuals with trichiasis who self-managed symptoms by epilating, there was a median of 2 eyelashes touching the eye (interquartile range 1–5), whereas As is commonly found in household surveys carried out during the day, we have an under-representation of males in the survey. As only those present at the household at the time of survey were enumerated , it is not possible to determine the true extent to which men were under-represented in the households sampled. It is possible that, given that both survey field researchers were female, there might have been higher uptake from female community members. This could have potentially been addressed with a stronger approach to community sensitisation in advance of the surveys. Our focus group discussion took place in an iTaukei village because when it was conducted we had not heard that epilation was also practised by other ethnic groups; it is possible that this influenced the choice of possible risk factors assessed at population level. A further potential weakness of our work is the inherent difficulty in standardising the diagnosis of TS, which was not a feature of the training and standardisation of graders carried out as part of the Global Trachoma Mapping Project. We trieIn this study we have highlighted an epilation behaviour that could significantly bias TT prevalence estimates. We conclude that epilation in the absence of trichiasis has the potential to impact programme planning for trachoma elimination in countries where this practice is common. Further studies in Pacific populations where kava is consumed should be undertaken to see whether the relationship with kava drinking seen in our study is true in other settings. Given the difficulties inherent in determining whether epilated eyelashes were in-turned, consideration should be given in future surveys to require the presence of TS in epilated eyelids in order to diagnose TT.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S1 Checklist(DOCX)Click here for additional data file.


The European Society of Clinical Nutrition and Metabolism (ESPEN) recently published new diagnostic criteria for malnutrition. The aim of this study was to evaluate whether malnutrition by the new ESPEN diagnostic criteria can predict long-term mortality in elderly inpatients. We conducted a prospective study in the acute geriatric wards. Malnutrition was defined according to the new ESPEN criteria and the Mini Nutritional Assessment (MNA), respectively. The survival status was determined by telephone interviews at 3-years. A total of 437 elderly adults were included. According to the new ESPEN criteria, 66 participants (15.1%) were malnourished. According to the MNA, 45 participants (10.3%) were identified as malnourished. The 3-year all-cause mortality was 41.7% in participants with malnutrition defined by the ESPEN criteria and 15.3% in participants without malnutrition (p < 0.001). After adjusting for relevant confounders, malnutrition defined by the ESPEN criteria was a significant predictor of 3-year all-cause mortality . However, malnutrition defined by the MNA was not a significant predictor of 3-year all-cause mortality . In conclusion, the new ESPEN diagnostic criteria for malnutrition are reliable in predicting 3-year all-cause mortality among elderly inpatients. In adults, malnutrition generally occurs when nutrient intake is consistently insufficient to meet individual nutrient requirements, and this imbalance between nutrient intake and requirements ultimately results in changes in body weight, body composition, and physical function2. In various study populations, malnutrition is known to be independently associated with various morbidities, mortality, functional impairment, poorer quality of life, and increased healthcare costs6.Malnutrition, also known as undernutrition, can be simply defined as “any nutritional imbalance”7. It is prevalent in elderly people, especially in hospitalized elderly patients7. In previous studies, the prevalence of malnutrition in elderly inpatients ranged from approximately 20 to 60%8. Fortunately, early detection and interventions for malnutrition  in elderly inpatients can significantly improve their major clinical outcomes, such as mortality and quality of life10. Therefore, nutritional status screening is currently recommended as a routine process across the continuum of care, especially in the acute care setting10.The prevalence of malnutrition increases with age, the number of comorbidities, and level of care2; or 2) unintentional weight loss >10% indefinite of time (or >5% over the last 3 months) combined with either of the following two items: BMI <20 kg/m2 if age <70 years or <22 kg/m2 if age ≥70 years; or low fat-free mass index (FFMI) <15 and 17 kg/m2 in women and men, respectively11. This new definition of malnutrition needs to be validated in specific populations. Therefore, we conducted this study 1) to determine the prevalence of malnutrition among hospitalized elderly inpatients according to the new ESPEN diagnostic criteria; and 2) to evaluate whether malnutrition by the new ESPEN diagnostic criteria can predict long-term mortality in these patients.Although malnutrition has been extensively studied for decades, there are no clearly accepted diagnostic criteria for malnutrition. In order to address this issue, the European Society of Clinical Nutrition and Metabolism (ESPEN) recently published a new consensus statement on the diagnosis of malnutrition, which includes a two-step process. First, a validated risk screening tool is recommended to identify individuals “at risk of malnutrition”. Second, in those who are at risk of malnutrition, two alternative ways are offered to diagnose malnutrition: 1) body mass index (BMI) <18.5 kg/mThis study is a post-hoc analysis of a prospective study that was conducted in the acute geriatric wards of the West China Hospital of Sichuan University and the Fifth People’s Hospital of Chengdu City. The study protocol was approved by the Research Ethics Committee of Sichuan University. All methods in this study were in accordance with relevant guideline and regulations. A written informed consent was signed by all participants or their legal proxies.During August to December 2012, consecutively admitted elderly patients (aged 60 years or older) in the acute geriatric wards of the two hospitals were invited to participate in this study. Patients who could not finish the face-to-face interviews and/or anthropometric measurements due to severe health problems were excluded. They generally had at least one of the following conditions: 1) diseases in the terminal stage; 2) severe cognitive impairment; and 3) delirium. In addition, patients with clinically visible edema were also excluded.2). We measured the calf circumference at its widest point using a flexible tape to the nearest 0.1 cm when the participant placed in the supine position, with the left knee raised and the calf placed at a right angle to the thigh. We measured MAC using a flexible tape to the nearest 0.1 cm at the mid-point between the tip of the acromion and the olecranon process of the left upper arm. WC was measured using a flexible tape at the top of the hip bone to the nearest 0.1 cm on the naked skin at the end of light exhalation with the subject standing. A preliminary study was conducted to assess the reliability of the anthropometric measurements using the intraclass correlation coefficient (ICC). The results showed an excellent test-retest reliability of the anthropometric measurements .The main baseline data were collected by trained interviewers through face-to-face interviews within 48 hours after admission. Additionally, three trained technicians performed the following anthropometric measurements: body weight, height, calf circumference (CC), waist circumference (WC), and mid-arm circumference (MAC). We used a wall-mounted stadiometer and a digital floor scale to measure body height and weight to the nearest 0.1 cm and 0.1 kg, respectively. BMI was calculated as the ratio between weight (kg) and squared height (m) . First, the nutritional status of each participant was assessed using the Mini Nutritional Assessment Short-Form (MNA-SF)12. A score of ≤11 indicated that a participant was “at risk of malnutrition”. Second, in the participants who were at risk of malnutrition by the MNA-SF, the diagnosis of malnutrition was confirmed according to either of the following criteria: 1) BMI <18.5 kg/m2; and 2) unintentional weight loss >10% indefinite of time (or >5% over the last 3 months) combined with BMI <20 kg/m2 if age <70 years or <22 kg/m2 if age ≥70 years.According to the new ESPEN criteriaMNA in this study).In addition, the nutritional status of each participant was also assessed using the full version of the Mini Nutritional Assessment (MNA). Participants with scores of less than 17 were classified as malnutrition  and instrumental activities of daily living (IADLs). The response to each item was “without help” (1 point), “with some help” (2 points) and “completely unable to do” (3 points). The validity and reliability of the two scales have been well established15. The subjects were considered having an ADL or IADL disability when they reported a need for help from another person in performing at least one ADL item (ADL disability) or one IADL item (IADL disability)15.We used the Older Americans Resources and Services (OARS) multidimensional functional assessment questionnaire16, and a score of ≥11 suggests depression16. Cognitive function was assessed using the previously validated Chinese version of the Mini-Mental Status Examination (MMSE)17. The diagnostic cut-off points for cognitive impairment are as follows: a score of ≤17 for less than primary school, ≤20 for primary school graduates, and ≤24 for high school graduates or those with higher education18.Depression was measured using the Chinese version of the 30-item Geriatric Depression Scale (GDS-30)The following covariates were also collected from the face-to-face interviews: age, sex, education level, physical activity, alcohol drinking status, and smoking status. The following comorbidities were identified according to hospital information systems: hypertension, diabetes, obstructive pulmonary disease (COPD), ischemic heart disease, stroke, chronic kidney disease, acute infection, cancer of any type, osteoarthritis, liver disease, gastrointestinal disease, urinary incontinence, and chronic pain. The information about nutritional supplements during hospitalization was also collected. Handgrip strength was also measured by trained technicians using a handheld dynamometer based on strain gauge sensors  to the nearest 0.1 kg. In addition, serum prealbumin and hemoglobin were measured.The survival data of the participants were obtained by telephone interviews at 12, 24, and 36 months during the 3-year follow-up period. These data were also confirmed using the Local Death Registry Database. Time to death was calculated as the time between the first interview and the date of death to the nearest one month.All statistical analyses were performed using SPSS 20.0 . The categorical data and continuous data were presented as absolute numbers and percentages (%), and median and interquartile range (IQR), respectively. To compare the differences between groups, we used the Pearson chi-squared test for categorical data and the Mann-Whitney U test for continuous data with abnormal distribution, respectively. A p value of <0.05 was considered statistically significant. Univariate Cox proportional hazard analysis was used to investigate the possible predictors of 3-year all-cause mortality. The results were presented as hazard ratio (HR) and 95% confidence interval (CI). In order to explore the independent risk factors of mortality, we also performed multivariable Cox regression models. Variables that exhibited a significant association in univariate analysis were considered to enter in the first step of multivariable Cox regression models. However, in order to minimize the effect of collinearity, CC and MAC were excluded from the multivariable Cox regression models. In addition, survival curves were estimated using the Kaplan–Meier method and compared using log-rank tests.Among the 532 individuals who agreed to join this study, 79 individuals were excluded Fig. . In addiCompared with the survivors, the deceased participants were significantly older , and more prone to suffer from tumor , ADL disability , IADL disability , depression , cognitive impairment , and lower hemoglobin   in the baseline investigation. The overlap between malnutrition MNA and malnutrition ESPEN is illustrated in Fig. According to the MNA, 45 participants (10.3%) in the baseline investigation were identified as malnutrition MNA was similar between the final study group and the group lost to follow-up . Similarly, no significant difference was identified between these two groups with respect to the prevalence of malnutrition ESPEN .In addition, the prevalence of malnutrition MNA, but the difference was not statistically significant . However, the prevalence of malnutrition ESPEN was significantly higher in the decreased group than in the survival group  . Table MNA was not a significant predictor of 3-year all-cause mortality . However, age , tumor of any type , and cognitive impairment  were significant predictors of 3-year all-cause mortality. In addition, the survival curves of the participants categorized by malnutrition MNA are presented in Fig. The 3-year all-cause mortality was 26.2% in participants with malnutrition ESPEN and 15.3% in participants without malnutrition ESPEN (p < 0.001). According to the Cox proportional hazard model, malnutrition ESPEN was a significant predictor of 3-year all-cause mortality . Age , tumor of any type , and cognitive impairment  were also significant predictors of 3-year all-cause mortality  in four diverse populations19. The prevalence of malnutrition was 14% in acutely ill middle-aged patients, 6% in geriatric outpatients, 0.5% in healthy old individuals, and 0% in healthy young individuals. Another study reported that according to the new ESPEN criteria , the prevalence of malnutrition was 6.73% in a population of geriatric inpatients with diabetes20. The corresponding prevalence in our study was 15.1%. Because of the significant heterogeneity of study populations, it was hard to make a direct comparison across these studies.Because the new ESPEN statement of malnutrition was only recently released, there have been only two published validation studies regarding itet al. found that malnutrition defined by the new ESPEN criteria increased 2.7 times the odds of death in the hospital among a population of elderly inpatients with diabetes20. Our study adds to this evidence that malnutrition based on the new ESPEN criteria also increases the risk of long-term mortality in elderly inpatients with acute diseases. Further prospective studies are warranted to confirm this relationship in different study populations.The association between malnutrition and mortality in various populations has been widely studied in previous studies. However, only one study demonstrated the association between the new ESPEN definition of malnutrition and mortality. In their study, Sanz-París 21. The significant heterogeneity between studies made it impossible to combine these results using meta-analyses.Our study demonstrated that malnutrition assessed by the MNA was not significantly associated with 3-year all-cause mortality. According to a recent systematic review, among the 20 included studies, three studies reported that malnutrition measured by the MNA was not associated with mortality, but there was a significant association in the other 17 studies11. In this study, we applied the MNA-SF as the screening tool. In fact, Nutritional Risk Screening 2002 (NRS-2002) and Malnutrition Universal Screening Tool (MUST) were also recommended by the ESPEN statement. The choice of malnutrition risk screening tools appears to affect the results of malnutrition diagnosis. In the future, it will be important to assess the validation of different risk screening tools, and their influence on the diagnosis of malnutrition and healthcare outcomes.The ESPEN statement of malnutrition recommended that “any validated risk screening tool” could be used for screening malnutrition risk, and this is the first and mandatory step in the diagnosis of malnutrition11. However, we did not use the FFMI in this study, because this study is a post-hoc analysis of a prospective study, and no data relevant to FFMI in the study population were available. This might induce bias on the identification of malnutrition. However, it is notable that devices for FFMI measurements, such as bioelectrical impedance analyzers (BIA), are not readily available for clinical practice. Therefore, the ESPEN consensus statement also argued that “it was crucial not to mandate FFMI for the diagnosis of malnutrition”11. Second, although we found that nutritional supplements were equivalent between the survivor group and the decreased group, we did not collect the information about nutritional supplements after discharge. This might induce a bias to the results, as there is a growing evidence that nutritional interventions  in elderly patients could improve their nutritional and functional status, and mortality rates23. Third, we excluded 95 patients in the final analyses, this might induce a bias to the results.This study has some limitations. First, the second ESPEN diagnostic criterion of malnutrition is based on the combination of unintentional weight loss, and low BMI or low FFMIThe new ESPEN diagnostic criteria of malnutrition is a reliable tool to predict long-term mortality in geriatric inpatients. However, these results on mortality do not preclude the value of both definitions (ESPEN and MNA) on other important clinical outcomes. Therefore, more prospective studies are warranted to evaluate the association between the new ESPEN definition of malnutrition and other clinical outcomes  in various populations.


Many mathematical models have been published with the purpose of explaining aspects of T-cell development in the thymus. In this manuscript we adapted a four-compartment model of the thymus and used a range of mathematical approaches with the aim of explaining the dynamics of the four main thymocyte populations in the mouse thymus, from the emergence of the first fetal thymocyte until the death of the animal. At various pre-natal and post-natal stages we investigated experimentally the number and composition of thymocytes populations, their apoptosis and proliferation, along with data from literature, to create and validate the model. In our model the proliferation processes are characterized by decreasing proliferation rates, which allows us to model the natural involution of the thymus. The best results were obtained when different sets of parameters were used for the fetal and post-natal periods, suggesting that birth may induce a discontinuity in the modeled processes. Our model is able to model the development of both pre-natal and post-natal thymocyte populations. Also, our findings showed that the post-natal thymus is able to develop in the absence of the daily input of bone marrow progenitors, providing more evidence to support the autonomous development of the post-natal thymus. The emergence of the embryonic mammalian thymus, its subsequent rapid development in the early stages of post-natal life and then its gradual involution later in life are complex processes that are incompletely understoodThe development of the fetal mouse thymus begins at mid-gestation when the thymus bud, an area around the third pharyngeal pouch488There are functional differences between the pre-natal and post-natal thymuses. Relative to the adult thymus, the neonatal thymus has greater thymocyte proliferation and a predominance of immature thymocytes17et al.For a long time it was accepted that the thymus does not contain any self-renewal capacity and that its thymopoiesis required a constant input of bone marrow progenitors. In spite of a considerable amount of research being devoted to the isolation and characterization of these progenitors, their molecular signature was not clearly identified in the adult mouse2021242627Molecular and cellular investigations provide meaningful, individual observations but from such static experiments it is difficult to obtain dynamic information. Mathematics provides the appropriate tools for simultaneously analyzing thymocyte dynamics and the propagation of a perturbation from a population to other thymocyte populations. Thymus functions and various aspects of thymocyte apoptosis, proliferation, selection and maturation were previously modeled by differential equations, cellular automata or agent-based models29303132293029Thus we arrived at two main classes of mathematical models (both based on decreasing proliferation rates), one which does not incorporate (M1) and another one which incorporates density-based control of population growth (M2). Each of these two classes of models were further divided into two variants, which allow (V1) or do not allow (V2) different sets of parameters in the modeling of the pre-natal and post-natal thymocyte dynamics. The models were separated initially on the basis of their fitting quality, and the models with poorer fitting were not pursued further. Models with comparable fitting were examined for their ability to model the dynamics of the thymocyte populations and to match crucial developmental time points in the development of the fetal thymus, from our data or from the literature.We modeled the development of the fetal and post-natal thymocyte populations, their proliferation and the dependence of the post-natal thymus on the inflow of progenitors from the bone marrow, on a time scale ranging from the emergence of the first fetal DN thymocyte until the death of the mouse, at approximately 2 years of age. We used our experimental data on pre-natal and post-natal thymocyte apoptosis, the numerical value and percentage of thymocyte populations at indicated pre-natal and post-natal stagesAll four variants are able to model both the growth and involution phases of the thymus from the appearance of the first fetal DN thymocyte until the final stages of mouse life. The results reported in To further investigate the fitting quality of the modeling, we examined the correspondence between the time points of the appearance of the DN thymocyte population in the fetal thymus as obtained using the simulations of all four models, and those reported in the literature34578Based on the fitting quality and the match with the emergence of the DN thymocyte population in the fetal thymus, the best approach to modeling the dynamics of the thymocyte populations in both the fetal and the post-natal thymus is the one with a decreasing proliferation rate and birth discontinuity of rates (M1.V1).Next we investigated the ability of the two selected variants of models  and these results are displayed below. Similar results were obtained using the model which also involves density-based control of growth (M2.V1), as both models behave similarly in post-natal life.The results displayed in It appears that the absence of bone marrow progenitors in post-natal life did not prevent the development of the post-natal thymocyte populations. In the absence of post-natal bone marrow progenitors, the thymus has a nearly identical output of mature thymocytes for the first six months of post-natal life, its most active period, suggesting that a functional thymopoiesis could occur in the absence of these progenitors.These results suggest that the absence of progenitors in the post-natal thymus has an impact mostly on the DN population, while its effect on the other three populations is minimal, mainly in the early stages (the first six months) of post-natal thymus formation. Even with the complete absence of progenitors we could have production of functional, mature thymocytes from that thymus, comparable with that of a normal, progenitor-fuelled thymus, in the first 6 months of post-natal life. It is likely that the pool of DN and DP thymocytes present in the thymus at birth could keep the thymus going for most of its post-natal life. The absence of bone marrow progenitors seems to have more significant effects on the thymocyte populations and on the production of mature thymocytes after 6 months of post-natal life, when the organ is normally becoming less and less active, and its cellularity and functionality are only a fraction of their peak in the first weeks of post-natal life.T-cell development in the thymus is a very complex phenomenon that is only partly understood. While the post-natal thymus is readily accessible to experimental intervention, the fetal thymus, particularly at the early stages of thymus organogenesis is much more difficult to manipulate experimentally. In spite of these difficulties a picture of early thymus organogenesis emerged, with the identification of the primordial progenitors in the murine fetal liver458Until recently, the view that thymus function depends on a constant inflow of progenitors from the bone marrow was considered a central dogma of thymopoiesis202123242627We intended to address the issue of thymus developmental autonomy by developing a mathematical model that could accurately describe the development of thymocyte populations from the emergence of the first embryonic thymocyte up to the death of the animal and assess the dependence of the post-natal thymus on the influx of bone marrow progenitors. Starting from a classical compartmental model of thymocyte dynamics, corresponding to the main four thymocyte populations29Nonetheless, there are some major differences in the ability of the models analyzed to fit the experimental data and to match specific time points in the development of thymocyte populations, primarily in the pre-natal period. In the model which involves density based control of growth (M2.V1), the onset of DP, SP4, and SP8 thymocyte development is several days later than the time point when they are already detected experimentally. Furthermore, the time delay in the transfer between fetal DN and DP compartments is much higher than the values reported in the literatureWhen the bone marrow progenitors are absent from the development of the post-natal thymus, the thymocyte populations still form, although with some differences. The most sensitive population is the DN subset while the DP, SP4 and SP8 are far less influenced by the absence of progenitors. The total number of thymocytes in the thymus developed in the absence of bone marrow progenitors is not significantly different from the thymus developed with progenitors for the first 6 months of the post-natal life, precisely the period in which the thymus is the most active. The impact of the absence of bone marrow progenitors on the thymocyte populations becomes more significant only in the later stages of post-natal life, at a time when the thymus has lost most of its cells and its functions have diminished anyway. It is likely that DN and DP thymocyte populations resident in the thymus at birth could sustain the thymic homeostasis for many months into the post-natal life.A rapid growth of the post-natal thymus in the first weeks after birth and the subsequent age-induced involution of the organ.Similar distribution of thymocyte populations in the thymus both in pre-natal and post-natal periods F and 2F.The absence of bone marrow progenitors has little impact on post-natal thymus development in the first 6 months, suggesting that the thymus could contain self-renewal capability.Although the two classes of models use different approaches to modeling the growth processes, there are several aspects which both of them reveal:Based on models characterized by decreasing proliferation rates, it is possible to show that the post-natal thymus could develop quasi-normally in the first several months of life with no inflow of bone marrow progenitors, a result in agreement with some recent experimental findings that question the dependency of the post-natal thymus of a constant inflow of progenitors from the bone marrow2627We used NMRI mice throughout our experiments, both female and male. The pregnancy in our experimental mice lasted 19.5 days, with the plug day considered the day 0 of pregnancy (E0.0). At indicated time points the animals were sacrificed by asphyxiation with carbon dioxide and their thymuses dissected out for further processing, as described below. The total number of thymocytes in each thymus was counted via trypan blue and a hemocytometer. The total number for each thymocyte subpopulation was obtained by multiplying the total number of thymocytes with the percentage of the respective population, as inferred from the flow cytometry dot plots. All the experiments on animals comply with European Convention for the Protection of Vertebrate Animals used for Experimental and Other Scientific Purposes , with all its subsequent revisions, and Directive 2010/63/EU on the protection of animals used for scientific purposes. The experimental protocol was reviewed and approved by the Ethics Committee of the “Victor Babes” University of Medicine and Pharmacy Timisoara.6 cells/ml. The cells were labeled with FITC- and APC-conjugated, rat anti-mouse CD4, CD8 antibodies  and propidium iodide for 30 minutes in the dark, at 4 °C and then washed twice with cold PBS. The cells were re-suspended in PBS and analyzed on a BD FACSCalibur cytometer with at least 20,000 events recorded. Apoptotic thymocytes were identified as propidium iodide-positive cells with lower forward scattering while the four thymocyte populations were identified based on CD4 and CD8 antibody staining. The data was analyzed and displayed with the WinMDI and FCS Express software packages .Time-mated pregnant mice were sacrificed at E17.5, E18.5, and E19.5, in the morning immediately after overnight birth . We used multiple litters of pups to sacrifice every 5 days up to day 50 after birth, and on day 80 after birth. Their thymi were dissected out and washed with cold PBS to remove the traces of blood. Then with the help of a syringe piston it was minced through a sterile wire mesh immersed in cold PBS. The thymocyte suspension underneath was recovered, centrifuged at 700 g and washed twice with cold PBS. Concentration of cells was adjusted to 1 × 10Mathematical models involving density-based regulation of the growth processδ is the degradation rate. The compartment corresponding to apoptotic cells has been introduced in order to decouple the transfer and death rates that appear in the other compartments and to reduce the degree of parameter non-identifiability. It is primarily a mathematical compartment, since dead thymocytes are not a typical population undergoing some sort of biological development. Each of the first four equations in The first four equations describe the rate of change in the number of thymocytes, based on typical terms describing proliferation, death and transfer, while the fifth equation models the compartment of apoptotic cells. This last compartment receives as input apoptotic cells from all the other compartments, as it is reflected by the first four terms of the fifth differential equation. The process of degradation of the apoptotic cells is modeled by the last term, where t0 represents the time moment the first thymic progenitor activates the process of fetal thymus growth, around stage E10.5. The parameters bN, bP, b4 and b8 control the deceleration of the proliferation rates while the values of the parameters cN, cP and c48 are related to the ratio between the number of thymocytes corresponding to the last stage of development and that corresponding to the first stage. Parameters KN and K in b(t) in the equation describing the dynamics of N(t) corresponds to the influx of thymic progenitors. By combining In b(t) are estimated from data together with the other parameters of the model but such that b(t0) = 10−7 (this corresponds to the assumption that t0 denotes the time at which the first thymic progenitors activate the process of the thymus formation).By fitting the data on thymocyte precursors during the fetal periodτN in As the differentiation process of DN thymocytes in DP thymocytes requires several daysbN. bP, b4, b8, cN, cP and c48;Parameters involved in the proliferation process: sN, s4, s8, s04 and s08;Transfer and export rates: dN, dP, d4 and d8;Death rates: δ;Degradation rate for the apoptotic cells: τN;Time delay corresponding to the differentiation of double positive cells from double negative cells: t0;Time at which  the first thymic progenitor initiates the thymopoiesis: KN and K, used in the density-based control of populations growth;Carrying capacities, β, b0, and τb. It should be noted that the parameter β arising in b0 and τb such that the number of progenitors at t0 is 1.Parameters controlling the variation of the number of thymic progenitors: These two classes of models involve several groups of parameters which have to be estimated in order to construct a model reflecting the behavior illustrated by the experimental data:As our aim was to model the overall dynamics of thymocyte populations from the fetal period until death of the animal, the first issue in modeling was to analyze whether the same parameter values are appropriate for both the pre-natal and post-natal periods. In order to answer this question we conducted some preliminary analysis for each of the two classes of models, considering both the case when the same set of parameters is used in pre- and post-natal stages and the case when there are no constraints imposed on the parameters values, i.e. the parameters values may have pre-natal and post-natal differences. The main point to notice is that by applying the same parameters in pre- and post-natal stages the quality of the models is significantly reduced, as illustrated by the mean squared error (MSE) values presented in cN, cP, c48, which are computed directly using the corresponding pre-natal values, i.e. cpostnatal = bprenatalcprenatal exp, the numbers of parameters to be estimated being, in this way, decreased by three. Thus we arrived at four variants of the mathematical modeling, corresponding to the combination between two classes of models, which either incorporate (M1) or do not incorporate (M2) density-based control of the population growth, each with two variants, which allow (V1) or do not allow a discontinuity (V2) in the proliferation function at the moment of birth. In the Results section, out of the two main classes of models we used only the variants characterized by different sets of parameters in pre-natal and post-natal stages . The models were separated initially on the basis of their fitting quality, and the models with poorer fitting were not pursued further. Models with comparable fitting were examined for their ability to model the dynamics of the thymocyte populations and to match crucial developmental time points in the development of the fetal thymus, from our data or from the literature.sN > dP + s4 + s8), ensuring that the number of DP thymocytes did not become smaller than that of DN thymocytes in the late stages of post-natal life, in agreement with the experimental findingsThe calibration of the models to experimental data was done by minimizing the mean squared error using a stochastic optimization procedure based on an evolutionary algorithm hybridized with a Nelder-Mead local optimization methodThe gray curves on the charts  correspoHow to cite this article: Zaharie, D. et al. Modeling the development of the post-natal mouse thymus in the absence of bone marrow progenitors. Sci. Rep.6, 36159; doi: 10.1038/srep36159 (2016).Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


The aim of the present study was to investigate how the video speed of observed action affects the excitability of the primary motor cortex (M1), as assessed by the size of motor-evoked potentials (MEPs) induced by transcranial magnetic stimulation (TMS). Twelve healthy subjects observed a video clip of a person catching a ball (Experiment 1: rapid movement) and another 12 healthy subjects observed a video clip of a person reaching to lift a ball (Experiment 2: slow movement task). We played each video at three different speeds . The stimulus was given at two points of timing in each experiment. These stimulus points were locked to specific frames of the video rather than occurring at specific absolute times, for ease of comparison across different speeds. We recorded MEPs from the first dorsal interosseous muscle (FDI) and abductor digiti minimi muscle (ADM) of the right hand. MEPs were significantly different for different video speeds only in the rapid movement task. MEPs for the rapid movement task were higher when subjects observed an action played at slow speed than normal or fast speed condition. There was no significant change for the slow movement task. Video speed was effective only in the ADM. Moreover, MEPs in the ADM were significantly higher than in the FDI in a rapid movement task under the slow speed condition. Our findings suggest that the M1 becomes more excitable when subjects observe the video clip at the slow speed in a rapid movement, because they could recognize the elements of movement in others. Our results suggest the effects of manipulating the speed of the viewed task on the excitability of the M1 during passive observation differ depending on the type of movement task observed. It is likely that rehabilitation in the clinical setting will be more efficient if the video speed is changed to match the task’s characteristics. Recent years have seen great advances in brain imaging technology, enabling many researchers to elucidate brain mechanisms that were formerly “black boxes”. Researchers have discovered that the mirror-neuron system discharges not only when an individual performs a specific action, but also while observing others’ actions in a macaque brain  in previous action observation studies has shown that the excitability of the primary motor cortex (M1) is enhanced in the area corresponding to the muscle involved in the movement  during action observation compared to the baseline condition  induced by TMS. We discovered that the excitability of M1 during observation of rapid movement was facilitated under slow speed conditions  were enrolled in this study after providing written, informed consent. All subjects were self-reported right-handers. Baseline characteristics of subjects are shown in Table The present study was based on the global guidelines for care in the use of TMS  and instructed to keep both hands in a pronated position on a horizontal board attached to the chair’s armrest. They were instructed to keep the right forearm as still and relaxed as possible while paying attention to the visual stimuli presented on the PC monitor. To ensure passive observation of the video clips, the experimenter’s only instruction to the subjects was “You should stay alert while observing a hand,” before starting the experiment.We shot two types of video for the experimental task: one was rapid and the other was slow. The definition of a rapid or slow task was whether or not the elements of the movements could be recognized at a normal playback speed. We shot the task movies with an electrode placed on the actor’s skin and set the timing of the TMS trigger by means of electromyogram (EMG) data during task execution.We used the same task in Experiment 1 for rapid movement as in our previous study  is widely used in softball and is the official ball of the Japan Softball Association. The ball was #3 size . The video was recorded using a Web camera  and had a duration of 7000 ms (210 frames). We played the video by presenting a series of single frames, each lasting 33.3 ms, at normal speed , which was sufficiently fast to produce an animation effect.In order to trigger stimulation at specific times, 210 individual frames were converted to JPEG files and shown in succession to obtain the animation effect. At normal speed, the presentation time of each frame was twice the length of the refresh interval used by the PC monitor . The differences in video speed determined the presentation time of each frame . The timing TMS trigger was established for each specific file: it occurred at the same point in the action on the video—for example, when the actors hand was opened fully. Previous studies have found that MEP amplitude correlates significantly with finger aperture during grasping movements and peaks when finger aperture is maximal  to combine the task movement recordings and the EMG data, and to establish the timing of the TMS trigger. The EMG data were analyzed using the root mean square (RMS) of every 33.3 ms, and the decision on the TMS timing was made by checking the JPEG file and the EMG data as described above. TMS was delivered twice in both experiments. In Experiment 1, we established TMS delivery times as in our previous study . TMS was delivered once for each video clip, randomly at “open” or “catch” (Experiment 1) and “open” or “lift” (Experiment 2). For each subject each speed condition was used in 20 trials. Ten trials used the “open” phase of TMS delivery and ten used the “catch” (Experiment 1) or “lift” (Experiment 2) phase. MEP amplitudes were calculated for each TMS delivery.We used a computerized pulse-generation system . To ensure that TMS was always delivered at the correct time and that the experimental design was correctly implemented, the speed order  was randomized by the experimenter, and the order of TMS delivery times (“open” or “catch”/“open” or “lift”) was randomized by the LabView system. Each of the six possible trial conditions (three speeds × two phases) was replicated 10 times for each subject, for a total of 20 trials per speed, and a further 20 trials were control trials involving TMS and MEP data collection at intervals of 10 s during a sham trial, giving a total of 80 trials per subject.Surface EMG activity was recorded in the first dorsal interosseous (FDI) and in the right abductor digiti minimi (ADM), using pairs of 9 mm diameter Ag-AgCl surface cup electrodes . Surface EMG signals were amplified and filtered at a bandwidth of 5–3000 Hz using a digital signal processor , and were transferred to a computer for off-line analysis, using an A/D converter .At the beginning of the experiment, we identified the optimal TMS coil position for evoking MEPs in both the right FDI and the right ADM (the hotspot). TMS was delivered to the left M1 hotspot, marked with a pen on a swimming cap covering the scalp of each subject. TMS employed a 70 mm figure-of-eight coil connected to a magnetic stimulator . The coil was placed tangentially to the scalp with its handle pointing backward and rotated approximately 45° away from the mid-sagittal line. Care was taken to maintain the same coil position relative to the scalp throughout the experiment. The resting motor threshold (MT) was defined as the lowest stimulus intensity that evoked an MEP at least 50 μV in amplitude in the right FDI and in the ADM in five out of 10 trials. The test stimulus intensity was set at 110%–130% of the resting MT and produced a control MEP with a success rate that ranged from 35% to 55%, mean 46.6 ± 5.4%, for Experiment 1; 33% to 51%, mean 44.2 ± 6.6% for Experiment 2. The mean size of the control MEP for the FDI and ADM was approximately 0.5–1.0 mV. Throughout the experiments, subjects were instructed to avoid inadvertent movements that could give rise to background EMG activity. For each muscle in each trial, the 20 ms period preceding TMS triggering was checked for background EMG activity.post hoc test for multiple comparisons for further analyses. In all analyses, the p level for statistical significance was set at p < 0.05. All analyses were performed using statistical analysis software .If background EMG data was found, data from both muscles in the trial were rejected. MEP amplitude (peak-to-peak) was measured over each muscle in every trial. MEP amplitude was analyzed using peak-to-peak values and expressed as a percentage of the mean amplitude under control conditions. The data were statistically analyzed using a one-way analysis of variance (ANOVA) with the factor “video speed”  to investigate whether the MEP amplitude was modulated compared with the control condition. Moreover, the data were analyzed statistically using a three-way analysis ANOVA with the factors “video speed” , “muscle” , “timing” ; open, lift (Experiment 2)). We employed Tukey’s Typical superimposed waveforms of MEP amplitudes in the three trials at different speeds of the right FDI and ADM, recorded from one representative subject, are shown in Figure F = 7.521, p < 0.001, effect size = 0.975, power = 0.406), but not found in the FDI  = 0.402, non-significant, effect size = 0.115, power = 0.035). In the ADM, a post hoc test revealed that there was no difference between the control condition and the three video speed conditions.A one-way ANOVA was performed and a main effect of SPEED was found in the ADM  = 3.417, p < 0.05, effect size = 0.049, power = 0.634). To analyze the interaction between speed and muscle, the data were statistically analyzed using a two-way ANOVA with the factors “video speed × muscle”  and “timing” . This revealed a significant effect of “video speed × muscle”  = 5.134, p = 0.0001, effect size = 0.158, power = 0.984). However, “timing” had no significant main effect  = 0, non-significant, effect size = 0, power = 0.050). Tukey’s post hoc testing detected significant differences in “the slow speed in ADM was 64.5% higher than the normal speed in ADM , the slow speed in ADM was 79.4% higher than the fast speed in ADM , the slow speed in ADM was 55.3% higher than the slow speed in FDI , the slow speed in ADM was 75.2% higher than the normal speed in FDI , the slow speed in ADM was 67.5% higher than the fast speed in FDI ”.The mean MEP amplitudes as a percent of control (±SE) induced in the right FDI and ADM in response to single-pulse TMS are shown in Figure Typical superimposed waveforms of MEP amplitudes in the three trials at different speeds of the right FDI and ADM, recorded from one representative subject, are shown in Figure F = 1.151, non-significant, effect size = 0.095, power = 0.281; ADM: F = 1.401, non-significant, effect size = 0.113, power = 0.337).A one-way ANOVA was performed but revealed no significant main effect of SPEED in either the FDI or ADM  = 0.954, non-significant, effect size = 0.007, power = 0.163), speed  = 1.031, non-significant, effect size = 0.015, power = 0.227), or timing  = 1.249, non-significant, effect size = 0.009, power = 0.199), nor were there any other significant interactions.The mean MEP amplitudes as a percent of control (±SE) induced in the right FDI and ADM in response to single-pulse TMS are shown in Figure In the present study, we turned our attention to the issue of different types of movement—fast (or rapid) and slow—and investigated the effect of the video speed of the action on the subjects’ action observation; in particular, whether video speed affected the degree of M1 excitation, as measured by the amplitude of TMS-induced MEPs.Some studies have shown that M1 excitability is enhanced by the social features that characterize an observed action . M1 excitability was modulated when observing a rapid movement at slow speed. Moreover, the ADM was significantly facilitated compared to the FDI when a rapid movement was presented at a slow video speed. Everyone expects to be able to recognize elements of rapid movement played at a slow speed that would not be visible to the naked eye at normal or fast speeds. On the other hand, we would not acquire new information such as kinematic movement cues from observing movement at a slow speed. Previous studies using fMRI have found that the PMv and IPL constituent parts of the AON are particularly involved in the subject’s ability to understand motor-related components of observed actions. They suggest that AON activation depends on whether movement elements such as kinematic cues are recognized or not  when the replay speed of a video clip of rapid movement was reduced, and the modulation of M1 excitability would be accompanied by AON activation, particularly the PMv and IPL. In contrast, the slow speed movement component of the present study and the arm crank ergometers task of a previous study suggest that the AON was not dependent on the speed of the task video, and that the subject would recognize movement elements without changing the video speed. Therefore, modulation of M1 excitability was not demonstrated under those conditions.In the present study, video speed modulated M1 excitability only in the ADM but not in the FDI. Previous studies revealed that the muscle-specific modulations of M1 excitability were highly specific to the type of grasping observed. In a whole hand grasp condition , the ADM was facilitated more strongly than the FDI. On the other hand, the FDI was facilitated more strongly than the ADM in a precision grip condition . Subjects underwent cathodal tDCS to the area of the AON, and M1 excitability during action observation was significantly reduced following cathodal stimulation  affects the impact of varying video speeds.Action observation is used in clinical settings where patients watch video sequences depicting activities of daily living, and perform the actions they have observed (action observation therapy). The results of this research, that reveal the impact of different video speeds, and their impact on AON activation will be valuable in clinical settings and, as there are a number of applications for editing movie speed, can relatively easily be made to match video speeds to those optimal for the type of observational movement task required. Further, there is the possibility of changing the video speed to the optimal speed for complex highly skilled movements in the future.Finally, we believe that the present study’s findings could be relevant to extending the power of action-observation approaches to the rehabilitation of stroke patients.TMo, NI, HN and TH conceived and designed the experiments. TMo, DM, TMa, AN and TH performed the experiments. TMo, KN, KF and TH analyzed the data. JN created the experiment program. TMo and TH wrote the article.This work was supported by a Grant-in-Aid for JSPS KAKENHI Grant Number JP16J05954 to TMo.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.


In this Technical Note, we describe an in‐house video goggles feedback system assembled using several commercially available products. This goggle video feedback system is currently being used at University of Louisville and Mayo Clinic for both CT simulation and linac treatment delivery. The setup details, including specific recommendations, are provided, along with an alternative option for using the video goggles system.PACS number: 07.07Hj I.(SD)=0.6 min/100 MU) with the aid of a visual feedback system, and further reduced to 0.9 min per 100 MU (SD=0.2 min/100 MU) with an addition of an audio coaching system.Respiratory gating and breath‐hold techniques are commonly used in radiation therapy to reduce the dose to the surrounding normal tissues and/or to limit the tumor's motion caused by the patient's breathing. Several studies have demonstrated that an external feedback coaching system can help patients maintain and reproduce breathing patterns during treatment, thus improving the delivery accuracy and efficiency.Besides the above‐mentioned investigations, other studies have also demonstrated the benefits of the video feedback system for motion management.II.As depicted in The first signal (S[1]) is reconnected back to the imaging monitor for normal workflow. The second signal (S[2]) is connected to the input of a video scaler to direct the signal to the goggles system and to an optional control room monitor. The video scaler is used to define the portion of the display the patient will see in the video goggles. The optional control room monitor is used to display the same video display that the patient is seeing on the video goggles. A dual DVI splitter should be purchased if the optional control room monitor would be used. The output signal S[2] from the video scaler is then connected to an HDMI extender transmitter via a DVI‐D to HDMI converter cable. Inside the treatment room, the HDMI extender receiver is permanently mounted on the wall near the conduit where the cat5e/6 cable is located. It is recommended that the location of the HDMI extender receiver be away from the primary beam to minimize the damage from radiation to the electronics. It is also recommended that the location of the HDMI extender receiver can be easily accessed by the therapists. An HDMI cable is used to connect from the output of the HDMI receiver to the video goggles.III.At University of Louisville, the system was just recently implemented for treatments of six breath‐hold gated patients on a Varian TrueBeam over an eight month period. At Mayo Clinic, the system was used to treat more than 100 breath‐hold gated patients on six Varian TrueBeam linacs and has been operational for two years. Our experience with the system showed that the patients tolerated it very well. The system has also been implemented for CT simulation of breath‐hold gated patients using the Varian RPM system and can be implemented on linacs other than the Varian TrueBeam, as well. The average time to prepare the goggles for treatment or simulation is approximately 1 minute. While we provide a few recommendations on how to test the functionality of the system, our main focus is to present the details on how to implement this in‐house system into clinical practice.A.The Vuzix Wrap 1200DX goggles used in our video goggles feedback system come with a rechargeable Li‐ion battery pack and a USB charging cable. We recommend that a USB connecter plug should be purchased separately so that power can be provided to the goggles in case the battery runs low while in use.B.Occasionally, the imaging signal from the linac will turn off if it detects a different output connection than the monitor due to a difference in the extended display identification data (EDID). Therefore, it is recommended that users program the distribution amplifier to store the desired EDID. The amplifier has a built‐in EDID management system that reads and stores the EDID from the linac's imaging monitor. Readers can refer to the user manual for a more detailed instruction on how to program the EDID for the amplifier.C.The video signal can be scaled, cropped, and panned in real time to display only the relevant information on the monitor to the patient. The tvONE1T‐C2‐750 video scaler  has two preset slots that can be used to program and store the settings. The customized settings can be varied depending on the manufacture and software version of the linac and Varian RPM system at the CT. The preset settings described in Appendix A (Table A1) is recommended to use to set the patient's breathing waveform for TrueBeam (version 2.0) linac.(1280×720 60Hz) to match the goggles' input resolution. It is highly recommended to have an external monitor available when first commissioning the video goggles feedback system if the optional control room monitor is not implemented. Once the output resolution is set, the settings can be stored in the preset slots in the video scaler. The signal can then be displayed in the goggles to adjust other customized settings such as zoom, crop, and pan.The video scaler must be set with the proper output resolution The video scaler has the option to display a stored static image for the patient to see during treatment when it is not necessary for patients to view their waveform. The software can be downloaded from the tvONE support software website.D.After the system is completely set up, it should be verified that the desired video screen of the patient's breathing waveform can be seen on the goggles' display. The goggles should be tested on the treatment couch with a volunteer prior to implementation. Several breathing patterns should be conducted and visually confirmed to check the waveform's amplitude and period, and to verify that the waveform on the goggle's display is correctly synchronized with the TrueBeam RMM workstation's monitor. The steps can be repeated at the Varian RPM system on the CT simulator to ensure the same level of synchronization can be achieved. Other quality assurance procedures such as signal reproducibility, image quality, and hardware and cable performance checks should be conducted to ensure the safety of the system. A review of the studies conducted by Jiang et al.B.1An alternative way is to use a goggles system with input from a tablet (if the readers don't want to change their current linac setup). For example, an Apple iPad operating in camera mode is placed on a stand in front of the monitor displaying the patient's respiratory waveform. The video signal from the iPad camera is converted from the 30‐pin to VGA so that it can be input to the VR2200 goggles system . (This iPad video goggles system was used at University of Louisville prior to implementing the current in‐house goggle system.) The goggles system is powered by an AC adapter provided with the goggle system. The disadvantage of this system is the instability of the setup. The iPad is held on a stand that can be easily displaced. Because the zoom is provided manually on the touch screen, subtle movement or adjustment results in a large change viewed by the patient. The quality of the video viewed by the patient is dependent on the angle of the iPad to the monitor and the lighting of the room. Since the iPad needs to be set up at the beginning of every treatment, the cable connections are less stable compared to the current option.Supplementary MaterialClick here for additional data file.Supplementary MaterialClick here for additional data file.Supplementary MaterialClick here for additional data file.Supplementary MaterialClick here for additional data file.


The turbulence regime near the crest of a biologically rich seamount of the Mid-Atlantic Ridge southwest of the Azores was registered in high spatial and temporal resolution. Internal tides and their higher harmonics dominate the internal wave motions, producing considerable shear-induced turbulent mixing in layers of 10–50 m thickness. This interior mixing of about 100 times open-ocean interior values is observed both at a high-resolution temperature sensor mooring-site at the crest, 770 m water depth being nearly 400 m below the top of the seamount, and a CTD-yoyo site at the slope off the crest 400 m horizontally away, 880 m water depth. Only at the mooring site, additionally two times higher turbulence is observed near the bottom, associated with highly non-linear wave breaking. The highest abundance of epifauna, notably sponges, are observed just below the crest and 100 m down the eastern slope (700–800 m) in a cross-ridge video-camera transect. This sponge belt is located in a water layer of depressed oxygen levels (saturation 63±2%) with a local minimum centered around 700 m. Turbulent mixing supplies oxygen to this region from above and below and is expected to mix nutrients away from this biodegraded layer towards the depth of highest abundance of macrofauna. Seamounts display various physical oceanographic processes, which have an effect on biogeochemical processes resulting in a large variability in the abundance of life . While sHere, we aim to learn more on the interaction between a steep confined seamount (sensu ), locateTen days of high-resolution moored observations have been made near the crest of an elongated seamount bounding the axial graben of the Mid-Atlantic Ridge 400 km southwest of the Azores . At its -1 current speeds.Below the single buoyancy package on top providing 240 kg net buoyancy, a 196 m cable holds 98 high-resolution temperature T sensors. The lowest sensor was mounted at 5 m above the bottom (mab). Two Nortek AquaDopp acoustic current meters were 2.5 m above the upper temperature sensor at 201 mab and, clamped to the cable, between the lowest and second-lowest T-sensor at 6 mab. As verified with pressure and tilt sensors, the top of the mooring did not move more than 0.3 m vertically and it never deflected more than 10 m horizontally, under up to 0.5 m s−4°C. Three sensors showed calibration problems or too high noise levels and are not further considered. Their data are linearly interpolated.High-resolution NIOZ4 T-sensors are used, for characteristics see . The sen−4°C of their preset values. The standard drift correction is requiring a statically stable density (temperature) profile for a section of data of at least the inertial period, in this area 0.84 days, but preferably 2–7 days. The calibrated and drift-corrected data are transferred to Conservative  Temperature (Θ) values using the GSW-software described in  = 1.1±0.3×10−2 m2s-1, with [<N>] = 3.8±0.5×10−3 s-1. For the CTD-site, the time and [560 760] m average turbulence values are about half an order of magnitude lower, 2±0.7×10−7 m2s-3 and 4±1×10−3 m2s-1, respectively, with identical mean N. The turbulence dissipation rate is roughly the same at the two sites for the interior, and especially for z > -650 m , whereas locally sponge abundances up to 1 ind/m2 were found (755 m). The sponges with the highest abundance and biomass in this area was Pheronema carpenteri. Gorgonians were restricted to the southeastern side and the summit of the seamount and were not found on the northwestern slope.At the southeastern slope, the region between 690 and 710 m was only scarcely inhabited. Slightly deeper, at 730 m, the highest abundance of organisms was found, whereas at a depth of >800 m low abundances were observed. We distinguished between 15 morphospecies of sponges plus 7 other non-sponge morphospecies. The highest density of sponges was observed at the southeastern slope of the seamount (0.3 ind/m-1 (top) is directed more or less southwest ward along the crest. The vertical current w does not show much spring-neap variation, neither smooth tidal variation  and four (ε) orders of magnitude. The mean values for the entire 10 days period are similar to the ones for the tidal period in The one tidal period of Figs ariation . It doesrameters , which v-5/3 e.g., [The short-term variability also exists in the temperature data, as is apparent in the overall variance spectra . Because/3 e.g., . Althougs,max to a roll-off frequency, here at about 80N. In both CM-spectra, the transition to the inertial subrange indicates the transition from Ek > w2, for σ < Ns,max, to Ek < w2, for σ > Ns,max. At these transition frequencies, which indicate the transition from 2D-anisotropic to 3D-isotropic full turbulence motions, the vertical temperature coherence is only significantly different from zero for the smallest vertical scales Δz ≤ 4 m (In the Θ-spectrum, the inertial subrange stretches from approximately the maximum small-2 m-scale buoyancy frequency NΔz ≤ 4 m . In the Turbulence values are high, half an order of magnitude higher at the mooring-site and about similar to within a factor of two at the CTD-site compared to values found elsewhere above sloping topography at about the same depths e.g., . Such laBetween the maximum buoyancy frequency of these small scales and twice its value, the vertical current variance exceeds that of the horizontal currents. It does so not only in the generally more turbulent near-bottom waters, but also at 200 m from the bottom. At the latter distance, where turbulent motions are less energetic and internal waves smoother, the current meter also shows an aspect ratio of 1 near the larger-scale buoyancy frequency. The transition to full 3D-motions, with aspect ratio of 1, is also observed in a recent five-line T-sensor mooring in the lower 100 m above a sloping bottom . Those mThe significance of the observed turbulence extent from the interior and from near the bottom for the local benthic fauna involve the supply of nutrients, oxygen and of particulate organic matter. High near-bed turbulence may promote resupension of organic particles sunken from the overlying water column. These particles could nourish filter-feeders such as sponges, crinoids and corals ,27. AlsoPheronema carpenteri. Hydrographic measurements on Condor seamount [In a study of the Condor seamount near the Azores island Faial,  found a seamount  revealedseamount ,37. Coldseamount ,39 whileseamount .Following a 2D high-resolution numerical model of internal wave breaking above steep topography , we expeFuture studies should reveal whether our observations are portable to other seamounts. The coincidence of strong mixing and concentrations of filter-feeding corals and sponges in our and many other studies, calls for multidisciplinary studies encompassing hydrography, chemical oceanography and animal physiology. Such would form an important contribution for advancing predictive models of the distribution of key species and habitats e.g.  which th


The results including the complication and continence rates for 3 types of continent urinary diversion were evaluated. From 1992 to 1998 we performed 58 continent urinary diversions after radical cystectomy for invasive transitional cell carcinoma (TCC) of the urinary bladder. All three types of continent diversions and ileal loop procedures were discussed and patient preferences were determined. The patient preference rate for continent urinary diversion was 96.6%, and half of these patients wanted to be completely dry. Mean age of the patients was 58.2 years. Of the 58 patients, 9 (15.5%) had a Kock pouch, 15 (25.8%) had a Kock neobladder and 34 (58.6%) had sigmoidorectal pouch (Mainz-II pouch). Early and late complication rates of the three different continent diversions were evaluated. The number of complications, such as urine leakage, pyelonephritis, hydronephrosis, reflux and stone formation, were similar in all three types of diversions. Two (5.9%) Mainz pouch II patients who had stopped oral alkalinization demonstrated severe hyperchloremic acidosis. Spontaneous pouch rupture occurred in 1 of the Kock pouches. Reoperation rates were higher with the Kock pouch and Kock neobladder cases. Daytime continence rates for the Kock pouch, Kock neobladder and Mainz II pouch were 77.7%, 86.7% and 100% respectively. Even though complete dryness may not be achieved in every patient, orthotopic bladder substitution appears to be the best choice after radical cystectomy. Although it carries the risk of life-long oral alkalinization therapy, the Mainz pouch II is associated with an excellent continence rate and may be a good alternative for patients who desire to be dry.


Nutritional problems are one of the most common disorders encountered in aging, and malnutrition, secondary to insufficient food consumption. Failure to diagnose malnutrition can increase the risk of illnesses and death. Our objective was to evaluate the nutritional status of elderly patients aged 65 years and older through a Mini Nutritional Assessment (MNA) scale and to determine its relationship with laboratory parameters.This is a single-center cross-sectional study which included 102 patients aged 65 years and older who presented to the Family Health Center (FHS) in the Cobanlar District in the Province of Afyon, Turkey. Anthropometric and biochemical measurements of the patients were obtained, and the MNA scale was administered to the patients using a face-to-face interview technique. In the statistical analysis of the data, categorical variables were analyzed using a Chi-square test, normally distributed data were analyzed using an analysis of variance (ANOVA), continuous variables with normal distribution comprising independent measurements were analyzed using an Independent Samples T-test, and data without normal distribution were analyzed using a Mann-Whitney Rank Sum test.Of the 102 patients included in this study, 45 (44.1%) were male and 57 (55.9%) were female. The mean age was 74.06±7.89 years (min-max: 65–92). Of these patients, 39 (38.2%) were found to have malnutrition, 19 (18.6%) were at high risk of malnutrition and 44 (43.1%) had a normal nutritional status.The findings suggest evaluating nutritional status in individuals aged 65 years and older in the population on a regular basis to reduce disease risk and mortality. Malnutrition, in simple terms, refers to the lack of nutrition and is characterized by the inability to consume the necessary nutrients required by the body.3Life expectancy has increased in parallel to the improvements in the quality of life and the decrease in the birth rates worldwide, and this has resulted in a gradual increase in the elderly population. According to the expectations of the World Health Organization, it is estimated that there will be approximately 1.2 billion elderly people in 2025, and this figure will reach two billion by 2050, with 80% of the elderly population in the world living in developing countries.4Elderly people (aged 65 years and older) made up 7.7% of the global population in 2013, and it is estimated that this will have increased to 10.2% by 2023, to 20.8% by 2050 and 27.7% by 2075.5Changes in food consumption occur as people advance in age. In the elderly, inadequate food consumption due to a loss of appetite results in a decrease in muscle and fat mass and the development of malnutrition.6Keeping a daily food log is extremely important in detecting conditions that develop secondary to nutritional status, although keeping such a food log can be difficult, which has led to the development of various screening tests for the measurement of nutritional status.The Mini Nutritional Assessment (MNA) scale developed by Guigoz et al. in 1994 has been used as a screening test for the detection of malnutrition.There are various studies of MNA and MNA-SF in different parts of the world. In a study by Kaiser et al. which aimed to detect cases of malnutrition in the community, MNA was used as a screening tool, and different rates were reported for the elderly people living in nursing homes, hospitals and in the community. The authors identified a correlation between malnutrition and dementia and sarcopenia and suggested that the MNA could be used to evaluate the nutritional status of elderly people.This single-center cross-sectional study was conducted at a Family Health Center (FHC) located in the Cobanlar District of the Province of Afyonkarahisar in Turkey. Individuals aged 65 years and older living in the district of Cobanlar were included in the study. Approximately 1,000 people aged 65 years and above resided in the district of Cobanlar, and around 120 individuals aged 65 years and older are admitted per month to the FHC. The study sample comprised of 102 patients who were admitted to the FHC between June 15, 2017 and August 1, 2017, who agreed to take part in the survey, and who had no severe psychiatric condition, dementia or communication problems . This study was approved by the Head Physician’s Office at the R.T Cobanlar District Hospital on June 1, 2017 with (23252106-000-67) and by the Okan University Clinical Ethics Committee on June 5, 2017 with decree number 84.The participants who met the study inclusion criteria were provided with general information about this study, and, sociodemographic data were generated through face-to-face interviews. Anthropometric measurements were made, and the data were recorded; information on health status was inquired, and biochemical parameters from the last one month were retrieved from the archive. The MNA questionnaire was administered to the participants, with an additional 13 questions asked to garner sociodemographic, anthropometric and general health data, including age, gender, educational status, household, height, weight, waist and hip circumference, dependency on bed, presence and identity of chronic diseases, blood pressure, total blood protein levels and fasting blood glucose. The MNA investigated anthropometric measurements , diet changes , overall assessment parameters  and personal assessment parameters .The questionnaire took approximately 5–10 minutes to complete, with height (cm) using a fixed height scale, weight (kg) using a fixed weight scale, blood pressure, waist circumference using a tape, hip circumference, mid-upper arm circumference and calf circumference all measured by the same person. Fasting blood glucose and blood protein levels were retrieved from measurements form over the last one-month period recorded on the patient’s chart.The validity and reliability of the MNA were evaluated by Guigoz et al. in 1994 and was deemed appropriate for the evaluation of malnutrition. A further three studies, two in France (155 and 120 patients) and one in New Mexico (347 patients) also validated the tool, which is applied in two stages. MNA-SF scale is administered in the first stage, and if the scores indicate risk of malnutrition, the MNA scale is administered in the second stage. The validity and reliability of the MNA and MNA-SF have been evaluated by Dr. Derya Sarikaya in Turkey, and are used as a screening tool for malnutrition in elderly patients.15The MNA comprises 18 questions, including 15 verbal questions and three questions based on anthropometric measurement. The scoring is performed on a 30-point scale, and the questionnaire starts with six screening questions yielding a maximum of 14 points (MNA-SF). These six questions (A-F) evaluate appetite, weight loss in recent months, mobility, psychological stress or acute disease, dementia or depression status, and BMI.18The continuous quantitative variables were expressed as number, mean and standard deviation; and the qualitative or score variables were expressed as number, median, 25th and 75th percentile. Continuous variables with a normal distribution of independent measurements were analyzed using an Independent Samples T-test, and data without normal distribution were analyzed using a Mann-Whitney Rank Sum Test. A one-way ANOVA was used for continuous variables, and a Pearson Chi-square test was used for categorical variables. A probability of P<0.05 was considered statistically significant, and all data were analyzed using the SPSS 21 software package.The study sample included 45 (44.1%) men and 57 (55.9%) women aged ≥65 years (mean= 74.06 years), who were residing in Cobanlar in Afyonkarahisar, located in western Turkey. The characteristics of the study participants are shown in Regarding residential status, 22 patients (21.6%) lived alone and 80 (78.4%) lived with their families, while 81 (79.4%) patients were independent, 15 (14.7%) were semi-dependent and six (5.9%) were bed bound.There are many causes of malnutrition in the geriatric population, and its early diagnosis and treatment can improve the prognosis of existing diseases in the elderly. Malnutrition in the elderly population requires a multidisciplinary approach involving both social aspects and interventions into eating habits and is more common among inpatients and homecare patients.19In a cross-sectional study conducted by Saka et al., 413 elderly patients presenting at outpatient clinics in the preceding 12-month period were evaluated with an MNA test, and findings showed that 13% of the study sample were malnourished, and 31% were at risk of malnutrition. Furthermore, the findings showed that patients with malnutrition and patients at risk of developing malnutrition had lower hemoglobin, serum total protein and albumin levels than the normal population, and comorbidities commonly accompanied malnutrition.Guigoz et al. found out that the rate of malnutrition is higher among inpatients, nursing home residents and patients living alongIn a study by Feldblum involving 204 patients, the findings showed that males are at a higher risk of developing malnutrition than females and that the risk of malnutrition increases with age.BMI, CC and MAC values have an important place in the diagnosis of malnutrition. In a study in China, X. Hu and et al. used the MNA test, and corroborating the results of the present study, they found the lowest BMI, CC and MAC values in the malnutrition group, that the values in the risk group were slightly higher, and that normal population recorded the highest values in both genders.The rate of malnutrition is rapidly increasing in parallel with the growth of the global elderly population. As malnutrition increases mortality, the use of nutritional screening tests among the elderly population would support the application of health measures to be taken in this direction.