Net PIPR has the potential to be a biomarker for PD, suggesting further study to determine clinical validity.Parkinson's disease (PD) is one of the most common neurodegenerative disorders, but it is often diagnosed after the majority of dopaminergic cells are already damaged. It is critical to develop biomarkers to identify the disease as early as possible for early intervention. PD patients appear to have an altered pupillary response consistent with an abnormality in photoreceptive retinal ganglion cells. Tracking the pupil size manually is a tedious process and offline automated systems can be prone to errors that may require intervention; for this reason in this work we describe a system for pupil size estimation with a user interface to allow rapid adjustment of parameters and extraction of pupil parameters of interest for the present study. We implemented a user-friendly system designed for clinicians to automate the process of tracking the pupil diameter to measure the post-illumination pupillary response (PIPR), permit manual corrections when needed, and continue automation after correction. Tracking was automated using a Kalman filter estimating the pupil center and diameter over time. The resulting system was tested on a PD classification task in which PD subjects are known to have similar responses for two wavelengths of light. The pupillary response is measured in the contralateral eye to two different light stimuli (470 and 610 nm) for 19 PD and 10 control subjects. The measured Net PIPR indicating different responsiveness to the wavelengths was 0.13 mm for PD subjects and 0.61 mm for control subjects, demonstrating a highly significant difference ( Parkinson's disease (PD) is a progressive neurodegenerative disorder. The primary symptoms are muscle weakness, tremor, and rigidity and these are the results of decreased stimulation of the motor cortex arising from the basal ganglia . SecondaThere is no single, well-established biomarker for a definitive diagnosis, suggesting the use of a series of more specific biomarkers . Visual via dopamine D2 receptors located on ipRGCs  among mammals, including humans, appears based on an opsin termed melanopsin that contrasts to rhodopsin and cone opsins found in conventional photoreceptors . A key fThe relationship between PD and irregular functioning of the retina provides an opportunity to develop a cost-effective and user-friendly system for measuring a PD biomarker. Measuring the rate and extent of change in pupil size and maximal pupil constriction at each stimulus wavelength is tedious for medical professionals. This is an exceedingly time-consuming process that requires evaluation of each single video frame and is thus prone to error. Assessment of ipRGC action now requires expensive equipment coupled with advanced interpretative mechanisms. The intent of our work is to demonstrate the utility of a point of care (POC) ipRGC analytic system easily and effectively deployed in any eye clinic or eye examination facility with little expense. The cost for our system: Ximena firewire camera: $700, LED infrared stimulator: $15, Narrow band path filter: $200, Radiometer: $700, Halogen stimulator: $200. We used our existing slit lamp biomicroscope (used every day for eye examinations) and simply attached the camera to it by the C mount. That is what makes this such a straightforward system, all eye clinics have a slit lamp biomicroscope, we simply adapted ours for about $2k for the testing in conjunction. We have implemented an automated system for tracking pupil diameters over time, making adjustments as needed, and simplifying extraction of parameters such as PIPR can substantially change the clinical accessibility of such a biomarker.Kalman filters provide a robust and accessible means of tracking parameterized objects in video by combining uncertain frame-by-frame estimates with uncertain state estimates in a Bayesian framework . This alIn this study, we have developed a real-time prototype that can simultaneously extract pupil size over time, enable adjustment frame by frame, and enable the extraction of experimental parameters to detect Parkinson's Disease. We have collected data for 19 PD and 10 control subjects to assess the abnormality of PD ipRGC function through the post-illumination pupil response (PIPR). The 19 PD subjects represent a range of PD severity with a mean Hoehn and Yahr rating of 2.3 and standard deviation of 1.2. In the H&Y rating system, 1 is for unilateral motor manifestations, 2 is bilateral with minimal effect to balance, 3 and 4 are progressively more severe and affecting balance, while 5 is unable to walk unassisted . The proThe program automates the process of tracking pupil contraction and dilation by extracting data frame-by-frame and fitting an ellipse on each frame image to track the pupil's size. The system was built using the Python programming language and the graphical user interface was written in PyQt5. To begin the process, after uploading the video, the user is prompted to click on a region inside the pupil of the image to get a center point of the pupil, and the rest of the process is automated. Radial lines from the selected center point are drawn in 30° arcs. The program computes the intensity gradient along each ray. Maximal gradients are points on the edge of the pupil. The length is averaged out to get the diameter of the pupil and then the program fits an ellipse around the pupil for each frame. This center and ellipse are then used as an initial estimator for the subsequent Kalman filter sequence.After fitting one frame, successive frames can be fit by a button press, with an optional choice of time span to automate before stopping. The program will save pupil size and location parameters for viewing and are also available for easy download for offline analysis. c and Yc) as both variables change slowly. There are two steps in the Kalman filter process - the prediction step and the update step, governed by Bayesian update rules as a linear quadratic estimator. We have set the initial center position based on the user input, and the initial radius of the pupil is estimated as described using the maximum change in the luminance gradient for a series of radial lines. The system tracks the covariance of the estimates in position and size over time along with the observation noise of R = 1 the process noise Q = 0.0002 which were fit by observation over a set of trials. In this study, we have adopted Fixed-Lag smoothing with N = 4  and the center position  in the left eye. Stimuli presented to the right eye consisted of long-wavelength (red) and short-wavelength (blue) narrowband 5-s pulses of light. This establishes the adequacy of the irradiance level used in this study to induce ipRGC action. Light stimuli were generated using a halogen-based fiber optic light source coupled with a custom-built Maxwellian-view optical system consisting of narrow bandpass filters of 25 mm diameter short wavelength, “blue” light, λmax = 470 nm; full width half maximum (FWHM) = 10 nm and long wavelength, “red” light, λmax = 640 FWHM = 10 nm) imaged to the plane of the pupil in conjunction with appropriate neutral density filters to alter power output to 8 or 30 μW . The stimulus pencil was constrained using an aperture of 10 mm in diameter. Each subject was run through three trials for each stimulus combination of 470 and 610 nm at both 30 μW high energy and 8 μW low energy. The average of three trials are used for analysis and the trials in which the blinking eyes are removed. While the stimulus is introduced into the dilated right pupil, the left pupil is concurrently videotaped. Each trial was run for 40 s: 5 s of pre-stimulus baseline, the light stimuli was then presented to the right pupil for 5 s, and recording continued for 30 s post-stimulus. Data was collected from a total of 24 PD and 11 control subjects. Among them 22 patients with Parkinson's disease have clinically confirmed PD, while two subjects were demonstrating parkinsonism symptoms - they are included as PD in this study. Two subjects were demonstrating parkinsonism symptoms due to presumed Lewy body dementia and multiple system atrophy, respectively.Subjects were secured in a completely dark room for 10 min prior to ipRGC assessment to facilitate dark adaptation. Pupillometry assessment was conducted in dim red room illumination to preserve the dark-adapted state during pupillometry testing. Each study subject was allowed to dark adapt for a 10 min period prior to ipRGC testing. Dark adaptation occurred following eye dilation (so at the end of the 20 min dilation period) and in the same room in which ipRGC analysis was performed. The right eye was dilated with 2.5% phenylephrine and 1% tropicamide. Dilation of the right eye was employed in an effort to maintain consistent retinal illumination within and between subjects during stimulation. After a 20-min dilation period, the ipRGC driven pupil response was measured −2 nm−1 resulting in irradiance stimuli of 11.421 and 11.995 log photons cm−2 s−1 at 640 and 14.621 and 15.195 log photons. cm−2 s−1 at 470 nm determined at the corneal plane, respectively. Given the older age of the participants, retinal irradiances were estimated based upon established corrections for age-related changes in the optical density of the media of the eye for stimuli >3° in diameter . Nerve fiber layer thinning has been associated with PD, therefore assessment of retinal nerve fiber layer thickness and retinal morphology was assessed in the dilated stimulated eye using automated optical coherence tomography   .The pupillary responses of 24 PD and 11 control subjects were recorded in this study. It has been observed that PIPR substantially correlates with baseline pupil diameter , leadingThe frame rate is 30 fps. The pupil diameters from all subject videos were extracted and stored for analysis. The stored files are then analyzed using python. We defined the pre-stimulus diameter as the average pupil diameter, over a 5-s period, before the light stimulus. Post-stimulus diameter was the average pupil diameter for the 30 s after the light stimulus. The measured parameters used to observe a difference between PD and control are post-illumination pupil response (PIPR) and Net PIPR Net PIPR.PIPR = Pre-stimulus Pupil Diameter – Post-stimulus Pupil Diameter.Net PIPR = Blue PIPR – Red PIPR.We also elaborated on these measures by normalizing by the pupil diameter creating the following additional measures: PIPR% and Net PIPR%.*100)/Pre-stimulus Pupil Diameter.PIPR Percentage = . For the 19 patients with Parkinson's disease, the average blue post-stimulus diameter is 4.72 (±0.08) mm and the average red post-stimulus diameter is 4.84 (±0.08), resulting in a difference of only 0.12 (p = 0.3). Notably, there also appears to be a visible difference in the time course of the average response after stimulus offset in PD compared to control subjects for both wavelengths of light.The pre-stimulus diameters for patients with Parkinson's disease were 5.63 mm for PD and Control subject groups, different by no more than 0.01 mm in either group or stimulus condition prior to light exposure. For the 10 control subjects, the average blue (470 nm) post-stimulus diameter was 4.42 (±0.08) mm, and the average red (610 nm) post-stimulus diameter was 5.02 (±0.08) resulting in a difference of 0.60 mm . This is in contrast to average PIPR parameters for each wavelength which only showed no significance (p < 0.14 red) or minimal significance (p < 0.03 blue) that is expected as it is not using subject contrast. A similar analysis was performed for the low energy (8 μW) stimulus showing that Net PIPR, as well as PIPR (blue/red), are not found to be statistically significant at low energy (p > 0.05). From these measured pupillary responses, the descriptive measurement of PIPR, Net PIPR, and Net PIPR Percentage were performed for high and low energy. In p = 0.1) while the correlation between Net PIPR and LED was 0.237 (p = 0.3). The relationships can be observed among all patients with Parkinson's disease analyzed in The distribution difference between PD vs. Control is illustrated in Our results show a significant difference in Net PIPR values between patients with Parkinson's disease and controls - The average Net PIPR in PD (0.13 mm) is significantly smaller than control subjects (0.61 mm). This supports earlier research indicating PD patients have a reduction in the sustained pupil responses, and suggests this parameter can be used as a biomarker for Parkinson's disease. Because all subjects chosen for analysis had approximately the same baseline pupil diameter, there was not a substantial difference in discriminability between Net PIPR and Net PIPR Percentage, reporting similar discriminability between PD (2.35%) and controls (10.82%) for Net PIPR Percentage. Notably, the two individuals with suspected PD demonstrated reduced Net PIPR consistent with patients with Parkinson's disease with values of −0.3 and 0.2, providing further evidence of their initial diagnosis.p < 0.03 all sizes vs. p < 0.001 under 5.7 mm). Kankipati et al.  suggesting that adequately controlling for pre-stimuli diameter of the subjects may be a crucial factor to using this biomarker.The analyses in this paper focused on the subjects with a similar baseline pupil diameter as has been observed in other studies . A simili et al.  investigi et al.  showed tp < 0.01) was minimally significant compared to Net PIPR in mm (p < 0.001). Joyce et al. measured PIPR 6 s after the light offset as previous studies  establishing the proposed parameters can be a metric to determine PD. The results of this study will inform a larger trial examining ipRGC function in various forms of parkinsonism related disorders and support the long term goal of identification of suitable retinal biomarkers for neurologic diseases implementing light-based PD therapy. However, further studies are needed to evaluate the hypothesis as our investigation is performed with small sample size and a limited range of pupil sizes.In this study, we examined the discriminability of Net PIPR and its potential as a biomarker for disorders affecting photoreceptors, such as Parkinson's Disease. Net PIPR and Net PIPR Percentage for distinguishing control vs. PD demonstrated show a high level of statistically significance (In this study, control subjects display a distinct but minimally overlapping Net PIPR compared to PD indicating its potential utility as a biomarker for PD consistent with the known melanopsin mechanism. The analyses were performed using a custom-built pupil-size tracking system for acquired video under repeated exposure to red and blue wavelengths of light in the contralateral eye. The robust user-interface facilitated direct observation of pupil-size fits, manual adjustments as needed, and recomputing of future fits to enable clinicians to efficiently extract the relevant parameters for Net PIPR. The analyses demonstrate the potential utility of this experimental paradigm and our online pupil-size tracking system improves clinical efficiency and accessibility as a diagnostic tool in evaluating patients with suspected Parkinson's disease.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by IRB, Edward Hines, Jr. VA Hospital. The patients/participants provided their written informed consent to participate in this study.TT, MA, and TX created the pupil tracking application and analyzed the data. AZ, RY, KC, MJ, YP, JC, and BG designed the experimental protocol and performed subject data collection. TT, BG, MA, and TX wrote 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.


Malnutrition in hospitalized patients heavily affects several clinical outcomes. The prevalence of malnutrition increases with age, comorbidities, and intensity of care in up to 90% of old populations. However, malnutrition frequently remains underdiagnosed and undertreated in the hospital. Thus, an accurate screening to identify patients at risk of malnutrition or malnourishment is determinant to elaborate a personal nutritional intervention. Several definitions of malnutrition were proposed in the last years, affecting the real frequency of nutritional disorders and the timing of intervention. Diagnosis of malnutrition needs a complete nutritional assessment, which is often challenging to perform during a hospital stay. For this purpose, various screening tools were proposed, allowing patients to be stratified according to the risk of malnutrition. The present review aims to summarize the actual evidence in terms of diagnosis, association with clinical outcomes, and management of malnutrition in a hospital setting. Malnutrition in hospitalized patients represents a heavy healthcare burden worldwide . Indeed,The increase in malnutrition-related diseases in people with multiple comorbidities is a growing health concern, and it is strictly related to both the aging of the general population and the improvement in healthcare ,6,7. Of Several factors contribute to the worsening of nutritional status during hospitalization: illness-related loss of appetite, fasting for diagnostic procedures, drug-related side effects, diseases that compromise the regular functioning of the digestive system, and the poor management of patient nutrition .Despite the relevance and the prevalence of the problem, malnutrition frequently remains underdiagnosed and undertreated. Diagnosis of malnutrition needs a complete nutritional assessment, which is often challenging to perform during a hospital stay ,2. ConseSpecific identification and optimal management of this clinical condition could improve the prognosis of malnourished patients, reducing both the length of the hospital stay and costs related to hospitalization .Malnutrition is a global health problem affecting more than a billion people of any age group ,11. DespThe European Society for Clinical Nutrition and Metabolism (ESPEN) defines malnutrition as “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat-free mass) and body cell mass, leading to diminished physical and mental function and impaired clinical outcome from disease” . The Ame2, or the combined presence of unintentional weight loss  associated to at least one of the following: reduced BMI , or low-fat free mass index  . Th. Th19]. Malnutrition in a hospital setting is a costly, morbid, potentially preventable, and treatable issue. Even though malnutrition is a well-known determinant of several serious complications, hospitalized patients are not regularly screened for nutritional status at hospital admission and are seldom diagnosed if malnutrition occurs during hospital stay ,20. NutrIn order to diagnose malnutrition, a 2-step approach has been recently recommended by the Global Leadership Initiative on Malnutrition (GLIM) in hospitalized patients: the first step consists of a screening within 24–48 h after hospitalization to identify subjects at risk of malnutrition using any validated screening tool; the second step includes the assessment for diagnosis and grading of severity in high-risk patients. Moreover, GLIM recommends to re-assess the nutritional status periodically during hospitalization . A comparison among three nutritional screening tools  in old hospitalized patients showed that MUST is the most sensitive, specific, and accurate to identify malnourished patients according to the new GLIM criteria for Malnutrition, despite being less rapid as compared to NRS-2002 and SGA ,17.Nutritional screening should be included in a defined clinical protocol, followed by concrete interventions when needed . A positMalnutrition affects all stages of life, from children to old individuals, but prevalence differs depending on factors such as age, geography, social condition, or the presence of specific situations such as edentulia ,25. NutrAccording to most studies, malnutrition prevalence in hospitalized patients ranges from 20% to 50%, according to the use of different diagnostic criteria and screening tools . Among gAbout 60–65% of hospitalized patients experience a poorer nutritional status as compared to healthy individuals ,32. IndeSeveral risk factors are described as associated with malnutrition in hospitalized patients . GeneralAging is associated with a higher risk of malnutrition because of several age-related changes able to affect nutritional statuses, such as deficit of physical activity, poor appetite, the feeling of unwantedness, or a sense of neglect. Furthermore, old age is characterized by a loss of taste, which can impact eating habits with negative consequences on health status . Other iFemale sex is also associated with a higher risk of malnutrition due to several factors such as longer life expectancies than men or a higher probability to suffer from adverse economic and social circumstances in old age . Low adherence to a Mediterranean diet is an important predictor of malnutrition in old patients ,52. Further factors include depression, low functional capacity, cognitive impairment, dysphagia, and eating-related problems ,53. OverAlcohol abuse, tobacco use, or socio-economic status are common independent risk factors of malnutrition ,43,59,60Malnutrition is mutually associated with several worse clinical outcomes . HoweverMalnourished old patients are at a higher risk of falls in hospitals when compared with those with preserved nutritional status. In particular, the risk of falls increases up to 8.4% and 6.2% in geriatric and internal medicine wards, respectively, and the global fall rate rises up to 31.6% up to 39.5% in patients ≥80 years . Old patDuring hospitalization, malnutrition is associated with reduced physical activity and a higher prevalence of frailty. Hospitalized patients with malnutrition showed similar muscle strength to well-nourished patients at admission but a reduction in mean muscle strength values at the end of hospitalization . HoweverHospitalized malnourished patients show a higher readmission rate (up to 180 days post-discharge) or in-hospital death risk than well-nourished patients. Several studies report a higher 30-day readmission rate in patients with poor nutritional status as compared to well-nourished patients ,77,78,79Despite a high prevalence of malnutrition, nutritional care is inadequate, and prevention measures are often not acquired . Data frA universal method for the diagnosis of malnutrition in a hospital setting is not available. Screening tests are the first step to evaluate nutritional problems and consist in the administration of a rapid and easy tool such as the malnutrition universal screening (MUST), the nutritional risk screening-2002 (NRS-2002), or the mini nutritional assessment short-form (MNA-SF). In patients who are at risk of malnutrition or malnourishment, according to the screening tests, a comprehensive nutritional assessment should be performed ,27. The Several conditions can be associated with a 35–40% reduced food consumption during hospitalization. Old people often experience impaired ability to eat and/or drink due to cognitive and functional limitations. Moreover, several chronic diseases such as diabetes mellitus or infections are significantly associated with inadequate nutritional behavior ,89,97. BESPEN guidelines suggest that old people at risk of malnutrition or malnourishment and their caregivers should receive individualized nutritional counseling by dedicated dieticians or nutritionists to improve the awareness about nutrition and support healthy nutritional habits . PatientIn old hospitalized patients, ESPEN guidelines recommend that food enrichment with natural ingredients  or specific nutrient preparations  may improve both protein and energy intake with meals and beverages through consumption of similar food quantities . FurtherConcentrated sources of nutrients that supplement a normal diet represent an option for the prevention and treatment of specific types of malnutrition. Oral supplementations can be represented by several elements or substances with a nutritional or physiological effect . SeveralEnteral (EN) and parenteral (PN) nutrition should be considered when patients are unable to meet energy and protein requirements according to diagnosis, clinical status, prognosis, and patient/family preferences. Conditions such as trauma, burns, and malignancy may require EN or PN to satisfy increased nutritional needs . EN shouA particular category of hospitalized patients with poor nutritional intake is represented by old people with advanced dementia. Both EN and PN have been discouraged in such patients because of increased risk of aspiration, gastrointestinal complications, fluid overload, infections, and bleeding . EN or PA systematic review and meta-analysis reported that nutritional support was associated with up to 53% reduced risk of mortality rate and a 27% decrease in mean mortality risk . PatientAccording to the results of a meta-analysis, supplementation with oral nutritional supplements (ONS) during and after a hospital stay resulted in a 16% decrease in hospital readmissions in old patients .Nutritional status in hospitalized patients is determinant for several clinical outcomes. However, to date, screening to detect patients at risk of malnutrition or malnourishment is still poorly performed on admission and during hospitalization. Several rapid tools are validated in the hospitalized population, including old patients. The key to success in the prevention and management of malnutrition in hospitals is given by a multidisciplinary approach that identifies and treats the specific risk factors for each patient. Technology increasingly shows a potential positive role in approaching the diagnosis and treatment of malnutrition. Implementation of new strategies, such as the use of machine learning-based algorithms to analyze electronic health records or food analysis consumption by an automatic system based on AI, may represent a promising future approach to improve screening and management of hospitalized patients at risk of malnutrition or malnourished.


The two most essential technical aspects of any gastrointestinal anastomosis are adequate perfusion and sufficient reach. For ileal pouch-anal anastomosis (IPAA), a trade-off exists between these two factors, as lengthening manoeuvers to avoid tension may require vascular ligation. In this technical note, we describe two cases in which we used indocyanine green (ICG) fluorescence angiography (FA) to assess perfusion of the pouch after vascular ligation to acquire sufficient reach. In both cases, FA allowed us to distinguish better between an arterial inflow problem and venous congestion than white light assessment. Both pouches remained viable and no anastomotic leakage occurred. Our results indicate that ICG FA is of great value after vascular ligation to obtain reach during IPAA. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice in patients with familial adenomatous polyposis (FAP), ulcerative colitis (UC) and well-selected patients with Crohn’s colitis . An AchiThe key in anastomotic healing is traction-free anastomosis that is well-vascularized . To acquIntraoperative fluorescence angiography (FA) using indocyanine green (ICG) is nowadays widely applied to assess colonic vascular perfusion and could contribute to the prevention of anastomotic leakage secondary to perfusion restriction , 7. So fIn this technical note, we demonstrate the potential value of FA in decision making after ligation of vessels to obtain adequate length for a tension-free anastomosis in two cases.As a standard technique, the completion proctectomy and IPAA were performed by a combined abdominal and transanal minimally invasive approach. After adhesiolysis, the root of the small bowel mesentery was mobilized to the level of the duodenum followed by multiple transverse peritoneal incisions. After completion of these steps, the terminal ileum was exteriorised through a Pfannenstiel incision or the stoma site. The yardstick for sufficient length was when the apex of the J-pouch reached 1–2 cm below the pubic bone. If these routine lengthening measures were insufficient, the ileocolic trunk and/or interconnecting terminal ileal branches were ligated. After sufficient length was achieved, the J-pouch was constructed by a side-to-side ileal anastomosis using a linear stapler. The anvil was placed at the apex of the J-pouch, after which the redundant blind loop was resected using a linear stapler and reinforced by sutures.After visual inspection of the pouch in white light, ICG  0.1 mg/kg/bolus was injected intravenously for FA. Imaging was performed by a laparoscopic 1688 AIM camera . After assessment by FA and necessary changes based on FA findings, a double purse-string single stapled ileo-anal anastomosis was fashioned followed by routine suture reinforcement of the anastomosis. A deverting ileostomy was only created in case of technical problems  or impression of suboptimal perfusion on FA. The ileo-anal anastomosis was assessed endoscopically within 2 weeks after surgery if a diverting ileostomy had been fashioned.® 4.0  (Fig. The first case was a 23-year-old female patient diagnosed with UC. With the disease not responding to medical therapy, she underwent a subtotal colectomy and ileostomy procedure. During this procedure, the ileocolic artery was already ligated. After a 4-month convalescence period, she was referred to our unit for the second stage of a modified two-stage IPAA procedure. Intraoperatively, there was insufficient length after applying the routine lengthening measures. To gain additional length, interconnecting terminal ileal branches were ligated. After pouch construction, there was the impression of impaired perfusion of the apex of the pouch Fig.  that wasThe second case was a 53-year-old man with a history of biological refractory UC, now in clinical and endoscopic remission under upadacitinib. Because of a sigmoid carcinoma, his immunosuppressants had to be stopped and surgery was indicated. This patient underwent a restorative proctocolectomy and pouch procedure as a planned single-stage procedure. After routine lengthening measures were performed, the reach remained insufficient and additional lengthening measures were indicated. The interconnecting terminal ileal branches were ligated. While the pouch was being constructed, the body of the pouch gradually became discolored Fig. . SubsequDuring IPAA surgery, it might be necessary to perform lengthening maneuvers that require vessel ligation in order to make the pouch reach , 10. ParThe cases described show that FA was of added value in intraoperative decision-making. In the first case, vascularization of a small area of the pouch body seemed compromised after ligation of both the ileocolic artery and interconnecting terminal ileal branches. FA assessment led to a change of management through suture reinforcement of the hypoperfused area and ileostomy formation. In the second case, even though pouch vascularization in white light seemed severely compromised, fluorescent enhancement occurred in the entire pouch, although in a delayed fashion. Discoloration of the pouch was therefore more likely due to venous congestion. Because of this finding, the surgeons proceeded with the construction of the anastomosis and an uneventful postoperative course followed.Although there is no agreement in the literature on this subject, FA assessment seems of value if devascularizing measures are required for additional reach. A limitation of this study is the subjective evaluation of the fluorescence images by the surgeon. Quantitative values are warranted to define a threshold for adequate perfusion and venous congestion. Moreover, there is no literature on postoperative outcomes after devascularization to acquire reach without FA assessment. Future comparative studies with larger cohorts are awaited to emphasize the potential added value of FA in pouch surgery, particularly in those cases whereby vessel ligation is indicated to obtain reach.ICG FA appears to be of value after ligation of vessels to obtain reach during IPAA.


Pseudocohnilembus persalinus and Uronema marinum , as parasitic scuticociliatid ciliates, were isolated from Scophthalmus maximus and Takifugu rubripes, respectively, in our previous studies. These ciliates are morphologically very similar; hence, it is difficult to identify specific scuticociliate species using traditional classification methods for performing taxonomic research and disease control studies.P. persalinus, U. marinum, and other 12 related ciliates, and a phylogenetic tree was constructed using 16 common genes. We chose the nad4 and nad7 genes to design specific PCR primers for identification.We annotated the mitochondrial genomes of these two scuticociliates on the basis of previous sequencing, including analyses of nucleotide composition, codon usage, Ka/Ks, and p-distance. We also compared the nucleotide and amino acid similarity of the mitochondrial genomes of P. persalinus and U. marinum were found to have a close evolutionary relationship. Although codon preferences were similar, differences were observed in the usage of codons such as CGA, CGC, and GTC. Both Ka/Ks and p-distance were less than 1. Except for yejR, ymf57, ymf67, and ymf75, the amino acid sequence similarity between P. persalinus and U. marinum was greater than 50%.P. persalinus and U. marinum were thoroughly compared to provide a reference for disease prevention and control. The specific PCR primers enabled us to identify P. persalinus and U. marinum rapidly and accurately at the molecular level, thus providing a basis for classification and identification.The mitochondrial genomes of The online version contains supplementary material available at 10.1186/s13071-021-04821-3. Miamiensis avidus, Uronema marinum, Uronema nigricans, Metanophrys orientalis, Pseudocohnilembus persalinus, and Pseudocohnilembus hargisi [Paralichthys olivaceus, Thunnus maccoyii, Scophthalmus maximus, and Dicentrachus labrax [In recent years, there has been an increase in the occurrence and extent of damage due to diseases of mariculture animals caused by ciliates. Scuticociliatosis, a disease caused by a type of ciliates known as scuticociliates, occurs globally and has led to a high fatality rate of fishes , 2. Scut hargisi –7. The s hargisi . Scuticos labrax , 9–12. Ts labrax . The ribs labrax .P. persalinus and U. marinum from Scophthalmus maximus and Takifugu rubripes, respectively [P. persalinus and U. marinum are dominant scuticociliate pathogens that are distributed in the north of China marine aquaculture area [P. persalinus and U. marinum [P. persalinus and U. marinum by comparing codon usage, Ka/Ks, and p-distance. We also revealed evolutionary relationships and mitochondrial genome differences between these species and 12 related ciliates by constructing a phylogenetic tree and comparing nucleotide and amino acid similarity of the mitochondrial genomes. Specific PCR primers for identification were designed according to the specific genes in the mitochondrial genomes of P. persalinus and U. marinum. These primers enable easy, rapid, and accurate species identification at the molecular level. The use of PCR primers to identify scuticociliates provided the basis for the classification and identification of scuticociliates.In a preliminary study, we isolated ectively , 16. P. ure area . In our  marinum , 16. In P. persalinus and U. marinum were deposited in NCBI (https://www.ncbi.nlm.nih.gov/) with accession numbers MH608212 and MG272262, respectively.The whole mitochondrial genome sequences of http://mitos.bioinf.uni-leipzig.de/index.py) [https://www.ncbi.nlm.nih.gov/orffinder/) tools were used to preliminarily annotate mitochondrial genome sequences. BLASTp and BLAST (https://blast.ncbi.nlm.nih.gov/Blast.cgi) were used to compare the preliminary results of annotation with encoded protein and rRNA sequences belonging to the reported related species in order to verify the accuracy of the results and make corrections. The schematic diagram was drawn using OGDRAW (https://chlorobox.mpimp-golm.mpg.de/OGDraw.html).The MITOS (ndex.py)  and ORF P. persalinus and U. marinum was compared. The RSCU was calculated using the formula described in the study by Sharp and Li [The codon usage bias of p and Li .P. persalinus and U. marinum. MUSCLE v3.8.31 (http://www.drive5.com/muscle/) software was used to compare the selected 25 common encoding genes of P. persalinus and U. marinum [Ka/Ks analysis was performed on 25 common encoding genes of  marinum . The KaK marinum , and MEG marinum .P. persalinus and U. marinum were downloaded from NCBI for phylogenetic tree construction. The sequences used for comparison and their GenBank accession numbers were as follows: Tetrahymena paravorax (Accession Number: NC_008338.1), Tetrahymena pyriformis (Accession Number: NC_000862.1), Tetrahymena thermophila (Accession Number: NC_003029.1), Paramecium caudatum (Accession Number: NC_014262.1), Tetrahymena pigmentosa (Accession Number: NC_008339.1), Tetrahymena malaccensis (Accession Number: NC_008337.1), Laurentiella strenua (Accession Number: KX529838.1), Thuricola similis (Accession Number: MW221262), Oxytricha trifallax (Accession Number: JN383843), Halteria grandinella (Accession Number: MT471317), Euplotes vanleeuwenhoeki (Accession Number: MK889230), and Urostyla grandis (Accession Number: KX494929.1). Sixteen common encoding genes of the complete mitochondrial genome of all ciliates were selected for phylogenetic tree construction. MUSCLE v3.8.31 software (http://www.drive5.com/muscle/) was used to compare individual genes among all 14 ciliates. The jModelTest 2.1.7 (https://code.google.com/p/jmodeltest2/) [http://nbisweden.github.io/MrBayes/manual.html) was used to construct phylogenetic trees with Bayesian inference [https://sco.h-its.org/exelixis/web/software/raxml/index.html) was used to construct a phylogenetic tree using the maximum likelihood (ML) method, with the bootstrap value set to 1000 [The complete mitochondrial sequences of 12 ciliates related to nference , and RAx to 1000 .P. persalinus, U. marinum, and 12 other related ciliates were analyzed [http://genoplotr.r-forge.r-project.org/) [The COGs and identity comparison of the whole mitochondrial genomes belonging to analyzed . Accordict.org/)  was usedP. persalinus and U. marinum were compared. Next, genes with both intraspecific relative conservatism and interspecific diversity among scuticociliates were selected. Among the selected genes, we chose nad4 and nad7. Primer Premier 5 was used to design specific primers based on nad4 and nad7. Primers P2-F (5ʹ-GTTATGGTTACAATGTTTGGTGTTAT-3ʹ) and P2-R (5ʹ-TATAGTACCAACATGTTTTCTCATCA-3ʹ) were designed based on the nad4 sequence of P. persalinus; primers P3-F (5ʹ-ATTGTTCTATGCTTATGCAA-3ʹ) and P3-R (5ʹ-TGTTTAGTAGAACTATTATTCAT-3ʹ) were designed based on the nad7 sequence of U. marinum. The PCR reaction system consisted of a 40 μL reaction mixture containing 20 μL KOD buffer, 0.8 μL KOD enzyme , 8 μL 2 mM dNTPs, 2 μL forward primer, 2 μL reverse primer, 2 μL model DNA, and 5.2 μL sterile purified water. The PCR reaction conditions were as follows: 94 °C for 3 min, 98 °C for 15 s, 56 °C for 30 s, 68 °C for 45 s, followed by 35 cycles and 68 °C for 5 min. Finally, the results were confirmed by agarose gel electrophoresis. The PCR products were sent to Sangon Biotech Co.  for nucleic acid sequencing, and the obtained sequences were compared with the target sequences.The whole mitochondrial genome sequences of U. marinum was 1470 bp longer than that of P. persalinus. The protein-coding gene region of U. marinum was 755 bp longer than that of P. persalinus and contained three more genes than that of P. persalinus. Although both P. persalinus and U. marinum have a strong AT preference, the AT preference of U. marinum was stronger than that of P. persalinus. The AT percent in the entire mitochondrial genome of P. persalinus was 77.04%, and that of U. marinum was 80.99%. The AT  of U. marinum was 4.44% greater than that of P. persalinus, and the AT (third) of U. marinum was 9.8% greater than that of P. persalinus. Figure P. persalinus and U. marinum. The order and distribution of heavy and light chains of all common amino acid coding genes were consistent. In U. marinum, ymf57, orf346, orf141, orf149, and orf202 were annotated, and the gap between rpl6 and ymf64, ymf63 and ymf65, and nad9 and cob was larger.According to the data given in Table P. persalinus and U. marinum had almost the same preference for relative synonymous codons, with only a slight difference. The usage of CAG that coded for Gln and AAG that coded for Lys in P. persalinus was higher  than that in U. marinum. In P. persalinus, CGA and CGC coded for Arg and GTC coded for Val. The usage degrees were 0.020, 0.061, and 0.140, respectively. However, in U. marinum, CGA and CGC were not used to code for Arg; in contrast, the usage of AGA for coding Arg was 0.353 higher than that for P. persalinus; moreover, GTC was not used in U. marinum to code for Val.Figure P. persalinus and U. marinum were less than one, which indicated that the encoding genes were mainly subjected to negative selection and the overall gene evolution tended to be conservative. Among the 25 common encoding genes, Ka/Ks of yejR was relatively high at 0.59, which suggested that it may have a relatively relaxed selection pressure. The specific value of Ka/Ks is shown in Additional file The Ka/Ks values Fig.  of 25 conad1-a, nad9, rpl16, rpl2, and rpl6, was higher than the p-distance obtained by the other two calculation methods, and the largest difference was observed for nad10. The codons of the cox2, nad1-a, nad9, rpl6, and rps19 genes did not show much difference in the p-distance calculated from the first and second bases or the third base and the CDS region, probably because Met or proteins with strong codon preference accounted for a large proportion of the proteins encoded by them.The data provided in Fig. P. persalinus and U. marinum were clustered together. P. persalinus and U. marinum belonged to Philasterida and were closely related to Paramecium caudatum which belonged to Peniculida. Other ciliates were in obvious clades: Hymenostomatida, Peniculida, Sessilida, Sporadotrichida, Urostylida, and Euplotida , nad10, rps12, nad7, tRNA-Phe (GAA), nad1-b, atp9, nad3, cob, rns, tRNA-Trp (TCA), cox1, nad1-a, nad4, and rnl was relatively high. This result is consistent with the identity of amino acid sequences. Among them, rns and rnl encoded rRNA; tRNA-Tyr (GTA), tRNA-Phe (GAA), and tRNA-Trp (TCA) encoded tRNA; nad10, nad7, nad1-b, atp9, nad3, cob, cox1, nad1-a, and nad4 were related to the biosynthesis of secondary metabolites, transport, and catabolism as well as to energy production and conversion; and rps12 was related to chromatin structure and dynamics as well as to the biosynthesis of secondary metabolites, transport, and catabolism. This finding showed that all 14 ciliates had similar secondary metabolite transport and metabolic patterns.In addition, the identity of several nucleotide sequences such as P. persalinus and U. marinum belong as a benchmark, in the order Hymenostomatida, which is most closely related to Philasterida, the common genes are not different in the order in which they are arranged, with only slight differences in the length and distribution of light and heavy chains. A large number of rearrangements occurred in other orders of ciliates, wherein the length and distribution of light and heavy chains are also very different. Moreover, Sporadotrichida and Urostylida have the same sort order of common genes, wherein rps12 is slightly distant from nad4 in Urostylida. In all 14 ciliates, rps19 and rpl2, and nad10 and rps12 are always next to each other.Combined with the analysis of the phylogenetic tree Fig. , it was P. persalinus and U. marinum, only the lanes using the P. persalinus gene as a template showed a single clear band. When the P3 primer was used to amplify the DNA of P. persalinus and U. marinum, only the lanes using the U. marinum gene as a template showed a single clear band. The result of sequence comparison showed that the amplified sequence of the specific primer was consistent with the target sequence.The result of comparison of the selected gene sequences and design of primers is shown in Fig. P. persalinus and U. marinum, which are very similar in morphological forms, the nad4 and nad7 genes were first proposed as molecular markers to differentiate these ciliate species. The interaction between nicotinamide adenine dinucleotide (NAD+) and NAD+--dependent enzyme plays an important role in cellular redox reactions, energy metabolism, and signal transduction processes. NADH dehydrogenase subunit genes include nad1, nad4, nad2, nad5 [nad7, and so on. Several studies have reported the application of NADH dehydrogenase subunit genes in species identification and genetic variation as interspecific genetic markers. The nad1 (NADH dehydrogenase subunit 1) gene has a higher nucleotide replacement rate and greater variability than other mitochondrial genes [Bactrocera zonata based on the nad1 gene and cox1  gene [nad1 and cox1 genes to identify Toxocara canis and Toxocara cati [nad4 (NADH dehydrogenase subunit 4) gene is one of the genes that evolved faster in the mitochondria. In the field of the classification, identification, and population inheritance of parasites, many scholars believe that the nad4 gene sequence is an ideal genetic marker. For example, Li et al. used nad4 to find interspecies differences among T. canis, T. cati, Toxocara malaysiensis, Toxocara vitulorum, and Toxascaris leonina from different regions [cox1 gene in Ascaridia galli was lower than that of the nad4 gene, and they therefore considered that the nad4 gene was more suitable than the cox1 gene as a molecular marker for studying the genetic variation of A. galli [nad7 gene was also considered to be an accurate fragment for species identification and phylogenetic reconstruction; it was used for identifying Amoebozoa [Mielichhoferia elongata [nad4 and nad7 genes were ideal genetic markers for studying the identification of ciliate species.In the present study, by performing a comparative analysis of the mitochondrial genomes of d2, nad5 , nad7, aal genes . Choudha 1) gene . Mikaeilara cati . The nad regions . Hao et A. galli . The nadmoebozoa  and was elongata , 36. ThePhilasterides dicentrarchi, which lives in sharks [P. dicentrarchi and M. avidus as different species using 18S rRNA, α-tubulin, and β-tubulin genes [P. persalinus was identified using a fluorescent dye-labeled SSU-rDNA-targeted oligonucleotide probe, which was optimized in fluorescence in situ hybridization (FISH) by Zhan et al. [P. persalinus and analyzed horizontal gene transfer (HGT) to understand its virulence [cox1 sequence were greater than those of SSU-rDNA in P. persalinus, P. longisetus, U. marinum, and M. avidus. The authors designed specific primers based on the cox1 sequence to successfully identify them [nad4 gene and the nad7 gene of P. persalinus and U. marinum. These primers could serve as a fast and accurate tool for species identification of scuticociliates. The function and composition of the mitochondrial genomes of P. persalinus and U. marinum were also analyzed in detail to provide a solid data foundation for follow-up research.The morphological forms of scuticociliates are too similar to be identified and distinguished visually. In recent years, because of the improvements in methods for obtaining molecular information of ciliates and the wide application of bioinformatics analytical methods, genetic analysis of ciliates has become a common method to study the phylogenetic evolution of ciliates. However, most gene analyses of ciliates were limited to basic gene sequencing, and the subsequent analysis was mostly limited to the analysis and comparison of SSU-rDNA and 18S rRNA. For example, Stidworthy et al. used SSU-rDNA to analyze and identify n sharks , and Felin genes . Howevern et al. . Xiong eirulence . Whang eify them . In the P. persalinus and U. marinum were thoroughly compared by analyzing nucleotide composition, codon usage, Ka/Ks, and p-distance. In addition, we compared amino acid and nucleotide identity of P. persalinus and U. marinum with 12 other related ciliates and constructed a phylogenetic tree. We have successfully designed specific PCR primers to identify P. persalinus and U. marinum using the nad4 and nad7 genes.In conclusion, the whole mitochondrial genomes of Additional file 1: Table S1. Ka/Ks values of 25 common encoding genes of P. persalinus and U. marinum.


In recent years, a vast body of research has investigated trends of declining alcohol consumption among youths. However, the extent to which restrictive-youth approaches towards drinking are maintained into adulthood is unclear. The aim of this study is to explore how young people’s relation to alcohol changes over time. Our data are based on longitudinal qualitative in-depth interviews with 28 participants aged 15 to 23 conducted over the course of three years (2017–2019). The study draws on assemblage thinking by analysing to what kinds of heterogeneous elements young people’s drinking and abstinence are related and what kinds of transformations they undergo when they get older. Five trajectories were identified as influential. Alcohol was transformed from unsafe to safe assemblages, from illegal to legal drinking assemblages, from performance-orientated to enjoyment-orientated assemblages, and from immature to mature assemblages. These trajectories moved alcohol consumption towards moderate drinking. Moreover, abstinence was transformed from authoritarian assemblages into self-reflexive assemblages. Self-control, responsibility, and performance orientation were important mediators in all five trajectories. As the sober generation grows older, they will likely start to drink at more moderate levels than previous generations. In recent years, a vast body of research has searched for explanations that indicate the trends of declining alcohol consumption among youths. No single explanation is sufficient to understand why such a large share of youths in high-income countries today choose to abstain from alcohol compared to previous generations ,2. EarliThe clear decrease in youth alcohol consumption during the past two decades is a cross-national phenomenon in high-income countries, which confirms the globalisation of youth culture . To undeOther research, however, proposes that decreased risk-taking such as heavy drinking is rather a sign of increased diversity when engaging in adulthood  or in adAlcohol consumption among 15- to 16-year-olds is well-studied, but knowledge on the extent to which modest drinking practices among youths will sustain later in their lives is scarce . HoweverYoung people’s drinking or abstinence is influenced and mediated by multiple interacting causes . When weassemblage refers to heterogeneous sets of relations composed of both human and non-human actors and agencies  is that important as such. It’s more like you have gotten accustomed to that it’s always around you. For example, I tend to go to all the Friday pubs, not that, “Oh, it’s Friday, let’s get drunk” but more like, “Ah, it’s Friday, a week of studies is over”, and I’ll hang out with all the students (…) and just celebrate the weekend. And then I have two or three beers because I’m there; it’s there. And that’s nice .As seen in the section above, turning 18 years old is one central actant in translating unsafe drinking into safe drinking. It is, however, also pivotal in the trajectory where legal aspects of drinking are highlighted in comparison to other elements in drinking. For example, Ella does not even consider drinking as a possibility before she turns 18. She argues that this is not a question of choice but a matter of whether someone has a right to drink or not. Since she and her friends are minors, they simply do not drink.Not that we are “abstainers”, but more like “we don’t drink”. We are minors—why would we? It’s as if there is a totally different perception of what’s allowed compared to earlier. (…) It feels like many people take them [the age limits] more seriously .The legal age of 18 defines the moment a person gains the right to drink; it distinguishes a minor from an adult. As this moment is upheld by legal institutions, it moves the actors who turn 18 towards an adult identity with corresponding rights, such as permission to develop a relation to drinking. Our three interviews with William exemplify the power of this legal age limit. At age 15, William finds drinking “stupid” and prefers to spend his time playing video games and sports. At age 17, he is still an abstainer but plans to start drinking when he turns 18. His action is bolstered by strict parental rules.They [the parents] say I shouldn’t start drinking… [and that I should wait until] I turn 18 .When I’m 18, I can drink, and they will trust me. (…) I want to devote myself to sports, and I can’t do that if I drink a lot. When I’m 18, or at graduation, there will be a champagne breakfast and such. Then I’ll probably drink. (…) First of all, I’ll have turned 18 and [at that point] we can celebrate something .William’s decision to consider drinking only after turning 18 is thus an outcome produced by multiple actants such as legal age, maturation, and trust of parents’ advice and rules.Many of our participants who turn 18 consider the translation of abstinence into drinking—especially into moderate consumption of alcohol—as a natural step in becoming an adult. At 18, you can enter into assemblages where alcohol functions as an actant that increases your capacities in diverse social events. You can go to bars and clubs (Victoria), partake in campus drinking activities , seek after-work drinking occasions (Emily), and partake in adulthood by joining your parents for a glass of wine (Alice). Olivia’s maturing process exemplifies this. When she turned the legal age of 18 and was allowed to buy and consume alcohol, her abstinence was translated into moderate drinking, which she considered a natural process. The translation increased her capacities to engage in adult-like sociability, “like having coffee with a friend at night, but drinking wine instead.”The third type of maturing trajectory concerning drinking deals with the opposition between assemblages of high performance and self-control on the one hand and assemblages of hedonism or pleasure on the other. In the high-performance assemblage, the actors aim to achieve excellent grades in school, aspire to successful careers, or perform at the top level in sports. Their focus on performance is boosted by both their parents’ and their own expectations to succeed. Sana’s quotation below exemplifies this assemblage and shows how it is often linked to responsibility towards one’s own parents.My parents would prefer me to do something they never had the opportunity to do, and that is to study and educate myself. (…) I try to prove myself to my parents; I want them to perceive me as a very responsible person. I want to make my own money, and I want them to trust me (…) because you never know what will happen. One of them could pass away, or we could lose the house and then it’s always good if I have money on the side to provide for us for at least a month or so .As Sana grows older, her performance orientation becomes more stressful as her friends and boyfriend expect her to spend more time with them and not so much time on her studies. Sana solves these conflicting expectations by continuing her sobriety and realising that in the future, she can participate in drinking situations sober while pretending to drink.Alice’s maturing trajectory, in turn, demonstrates a case in which the interaction between different assemblages does not lead to conflict between various expectations. Instead, the diverse assemblages fold into one another to enable new possibilities for her and enhance her capacities for pleasure and enjoyment in life. First, her engagement in elite sports—a high-performance assemblage that builds on relations of regular exercise, rules of abstinence, self-control, lack of time, and uncomfortable feelings in drinking settings—hinders drinking and makes it appear unattractive and unhealthy.I have never had the feeling of wanting to try it out [drinking]. I think it seems scary to lose control, sort of, and I don’t like those settings. (…) It seems uneasy. (…) I can’t see a reason for it. But, well, it has to do with health, too, why I wouldn’t .One year later, her high-performance assemblage (where she now combines elite sports with a job) still keeps her abstinent, but she recognises that drinking might be fun.First, I thought it could be fun, but then I had to work early the morning after, and I had practice. I was considering it, but it didn’t happen. Well, I don’t know, I might be a bit more attracted to it .In the last interview, however, she describes how her high-performing assemblage has undergone chains of translations that have made room for a new relation to drinking. With the influence of her friends and sister, she has started to drink moderately and learnt in the process that alcohol as an actant does not necessarily diminish her body’s capacities for action and well-being but rather—when consumed in the right and controlled way—increases them so that she can better enjoy the encounters with people, food, drinking settings, dancing, and herself.I have a friend, and when I got to know him more, we started to hang out and drink beer together. (…) I have realised that it is a way to meet people in society today (…) I think one beer tastes good, it is a nice beverage with food, sort of. (…) It feels extra luxurious (...) I become a bit more relaxed, and things can be a bit more fun. (…) On occasion, I have felt this feeling of panic in alcohol environments, that I am not comfortable in the situation (…) I just want to leave. (…) I have managed to overcome that a little. My sister knows how I feel, so she tried saying to me, “Come on”, tried to make me dance and eventually she managed to and then I overcame [my fear] … I went from feeling really uncomfortable to actually enjoying myself .The fourth type of trajectory in relation to drinking deals with the opposition between immature and mature intoxication. The assemblage of heavy drinking becomes—as time passes—modified by linkages that increase heavy drinkers’ capacities to drink in a more controlled, responsible, and personal way. Oliver describes this in the following way:It feels more fresh now, sort of. Before [the drinking] could be more frowzy, but now… I have more control over myself. That has changed. But I do the same things. (…) Take more responsibility, am older and hang out with older people. I don’t have to go out partying just because everybody else does it. Now I have other friends to watch a movie with. (…) I have more options of what to do. More money and more diversity. Before, I could go out drinking because I had just turned 18 and everybody wanted to go out. Now I’m 20, and I can sit and knit a sweater if I want to [laughter], and that wouldn’t be a problem .As our heavy drinking participants become older, their assemblages may undergo multiple “chains of translations” that can increase, decrease, or momentarily stabilise their drinking. For example, when Oliver focuses on his studies, this results in momentary decreases in his heavy drinking. When his romantic relationship breaks down, and he becomes single, this culminates in an increase in his drinking, and when he notices that drinking makes him look obese, this, in turn, for a while, decreases his drinking. The next excerpt from Thomas exemplifies how in the maturing process, heavy drinking habits tend to diversify through encounters with alternative drinking styles:I drink a lot less nowadays. (…) I know I have more control now. It’s not that I drank myself under the table every weekend, but it doesn’t happen as often that I get that drunk. And that’s because, I think, I don’t find it as fun anymore. (…) I’ve started to like red wine and beer too. (…) In that sense, I’ve started to drink in other social settings. Not just to get hammered. I drink because I enjoy it. Is it good for me?—That I don’t know .For many of the heavy drinkers, encounters with intoxication have increased their capacities to reflect on their drinking. Thus, previous negative drinking experiences have become actants moving them towards a more moderate drinking assemblage. For example, at the ages of 18 and 19, Lily first drank heavily with her girlfriends at home parties and bars—especially when she had finished upper secondary school and started working while still residing at her parents’ house; she had money to party. She describes how things often got out of hand, how her parents expressed concerns over her drinking and how she found out that her grandfather had previously experienced alcohol problems. These encounters made her reflect on her drinking. Later, she also realised that drinking caused anxiety and disturbed her studies.I have had anxiety [after drinking]. It’s felt unnecessary to drink because I know it will make me feel bad. I’ve had depression and take antidepressants too. Sometimes the anxiety gets worse the day after and the few days after drinking. (…) I don’t want that anymore because I don’t want to feel that way. (…) I’d rather concentrate on my studies .These negative experiences and her concerns over her health translated her heavy drinking trajectory into a moderate drinking trajectory. In our data, heavy drinkers describe similar kinds of translations. As they accumulate intoxication experiences, they not only translate their relationship with drinking into a more mature, responsible, and controlled one but also become more ambivalent and cautious. The learning-by-doing introduces actants to their heavy drinking assemblage, which decreases their desire to drink. They relate concerns linked to health , risks of drinking , and appearance .On the other hand, in our data, there are also participants who—despite developing an awareness concerning the risks of heavy drinking—state that for a few more years, they can continue to drink heavily, unhealthily, and irresponsibly since they are still young. For example, Thomas insists that his heavy drinking eventually will decrease.I don’t think I drink an awful lot, considering that I am 21 years old. I would not regard myself as an alcoholic. (…) You know it’s not good for you to drink, so you will scale down eventually. But I want to have fun now while being young, so I do it anyway .The last trajectory concerning drinking deals with the tensions between authoritative and self-reflexive forces in abstinence. The participants’ abstinence is first conveyed by an authoritative assemblage with actants such as religious beliefs, parental rules, subcultural norms, temperance movements, or political values, but later mediated in conjunction with a more self-reflexive assemblage related to personal reasons, acknowledged feelings, and authentic individual experiences. Through these chains of translations, abstinence becomes modified into more nuanced relational forces. For example, when Adina is 18 years old, one of the driving actants in her abstinence assemblage is religion—she does not drink because she is a Muslim. Two years later, her interview illustrates that the relational agency of her religious beliefs has weakened, and her abstinence is further moved by actants that are associated with personal concerns, experiences, and choices.I still don’t drink (…); my thoughts about it are still the same. (…) And I have maybe developed a broader picture of why. That it’s not the best and you can have fun without drinking. Before, when I was younger, I thought mainly about religion, but when you get older and start thinking… that you are not aware of yourself and such [while drinking], that causes concerns. You get more concerned about yourself somehow. Especially if there are things happening that are not good, that you can’t trust everyone. But I discovered that later, for me, I should actually not drink. (…) I’ve reached this age and made my own decision, and I will continue with it, to not drink .Similarly, in Mateo’s abstinence trajectory, the primary actant is first a figure of authority, his father, who argues abstinence to Mateo by maintaining that drinking would ruin his health, diet, and training schedule in sports.I know what my father would think about parties and such. He doesn’t approve. He would be very disappointed if I wanted to do it, but I respect that he doesn’t want me to. So I won’t. (…) My friends in school, they know me, and they know that my father doesn’t like it. So, they wouldn’t ask. (…) He tells me, “You should not drink” since he knows about my sport and that. He told me, “It would ruin your exercise and condition”. (…) If I were an adult, he wouldn’t be angry .One year later, Mateo interestingly finds himself in his father’s shoes and presents himself, his studies, his exercise, his risk of addiction, and saving money as actants that increase his capacities to stay sober.I don’t drink because my exercise would crash. It ruins your health, (…) diet and the training program that I have set up myself. I don’t find it important to drink and such. You know you get addicted and such. (…) I don’t want to take the risk. (…) It’s sort of a matter of principle that I learned myself. (…) I can focus on studying and exercising instead of partying and drinking and spending money on such things .In the article, we have analysed 28 complete cases of in-depth interviews conducted over the course of three years (2017 to 2019). The study deepens our understanding of how emerging adults approach alcohol over time. As the study results are based on a small purposive sample, one limitation could be the lack of generalisability of the results to Swedish youths in general. Social desirability bias in self-reported data should also be considered. However, by including interviewees from different sociodemographic backgrounds and by interviewing the same interviewees three times, the study is able to both capture the variation in young people’s drinking and abstinence trajectories and show how these trajectories are influenced by diverse kinds of material settings, relationships, health concerns, interests, emotional issues, practices, and habits.Our analysis identifies five trajectories that describe what kinds of chains of translations young people’s relation to alcohol have undergone over time. The first trajectory shows that young people consider underage drinking unsafe. It is related to informal spaces , vulneraThe second trajectory demonstrates how the accepted time to start drinking has moved from early adolescence to the moment of becoming a legal adult. If, for the earlier generations, the subcultural norms, group pressure, and intoxication provided the “social clock”  for the The third trajectory demonstrates the opposite displacement in young adults’ passages to adulthood. While the first and second trajectories exemplify in what way the current teenagers’ childhood lasts longer than that of the earlier generations , the thiThe fourth trajectory also displays how in heavy drinking assemblages, the maturation process means embracing relations that increase heavy drinkers’ capacities to act responsibly, controlled, and reflexive. This trajectory further concretises how young people, through multiple encounters with intoxication, learn to realise that heavy drinking is a risky and unhealthy practice. This learning-by-doing intoxication introduces to their heavy drinking assemblage actants that link their drinking to diverse physical, emotional, and social concerns and modify their relation to drinking to ambivalent and cautious ,33. ThesThe last trajectory expresses how abstinence in emerging adulthood is transformed from authority-related ideological, religious, and parental justifications towards personally experienced reasons, and in these, chains of translations become more mediated by individualised concerns. Although research suggests that abstinence might not be as socially sanctioned among youths in some contexts , youth nOverall, our results point out how young people’s relation to school, family, leisure, and the labour market is influenced early on by expectations in which the individual responsibility to exercise self-control, gain self-knowledge, and implement self-improvement is emphasised as an important element in becoming an authentic and successful person ,38. ThesOur study suggests that when the “sober generation” grows older ,10, it i


To compare dementia prevalence and how it varies by socioeconomic status (SES) across the USA and England.Population-based comparative study.Non-Hispanic whites aged over 70 population in the USA and England.Data from the Health and Retirement Study and the English Longitudinal Study of Ageing, which are harmonised, nationally representative panel studies. The sample includes 5330 and 3147 individuals in the USA and England, respectively.Between country differences in age-gender standardised dementia prevalence, across the SES gradient. Dementia prevalence was estimated in each country using an algorithm based on an identical battery of demographic, cognitive and functional measures.Dementia prevalence is higher among the disadvantaged in both countries, with the USA being more unequal according to four measures of SES. Overall prevalence was lower in England at 9.7% (95% CI 8.9% to 10.6%) than the USA at 11.2% (95% CI 10.6% to 11.8%), a difference of 1.4 percentage points (pp) (p=0.0055). Most of the between country difference is driven by the bottom of the SES distribution. In the lowest income decile individuals in the USA had 7.3 pp (p<0.0001) higher prevalence than in England. Once past health factors and education were controlled for, most of the within country inequalities disappeared; however, the cross-country difference in prevalence for those in lowest income decile remained disproportionately high.There is inequality in dementia prevalence according to income, wealth and education in both the USA and England. England has lower dementia prevalence and a less steep SES gradient. Most of the cross-country difference is concentrated in the lowest SES group, which provides evidence that disadvantage in the USA is a disproportionately high risk factor for dementia. This is the first study to compare dementia prevalence across countries using the same survey methodology and the exact same measure of dementia. The surveys have similar sample selection and questionnaire design. We standardise our estimates by age and gender to the English population aged over 70 in 2016. Any differences in overall prevalence across the two countries should represent true differences.We measure the socioeconomic status (SES) gradient of dementia across four different measures of SES: income; education; wealth and non-housing wealth.Dementia disproportionately affects the most disadvantaged in both countries, although the gradient is steeper in the USA according to all four measures of SES.We do not ascertain dementia directly but predict cases using a common battery of measures in English Longitudinal Study of Ageing and Health and Retirement Study. One of the SES measures, education, is also used as a predictor of dementia.Dementia, a severe and irreversible decline in memory and other cognitive functions, is a major and increasing global health challenge. It is the fifth leading cause of death globally and is one of the most common comorbidities for COVID-19 morbidity.3 4Americans are more likely to be in poor health than their English counterparts in multiple dimensions, including heart disease and diabetes.1110.1136/bmjopen-2020-045186.supp1Supplementary dataThe Global Burden of Disease Study (GBD) reported that in 2017 among those aged over 70, the USA had a lower overall prevalence of dementia at 7.89% compared with the UK at 8.91%.13In this study, we compared dementia prevalence in England and the USA among non-Hispanic whites aged 70+, and how it varied across the SES gradient of each country. Location-specific inconsistencies caused by differences in diagnostic practices were not an issue in our study because we used an identical case definition for dementia, and the surveys in the analysis shared the same design and sampling techniques. More specifically, we used two large surveys, the US Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA), that contain a battery of the same demographic, cognitive and functional measures, and we applied the same prediction algorithm in both countries to detect undiagnosed as well as diagnosed cases. We compared dementia prevalence within and across England and the USA using important indicators of SES, specifically: income; education; wealth and non-housing wealth.Data were extracted from the 2016 and earlier waves of the HRS and ELSA, which are nationally representative biennial surveys of the USA and English populations, respectively.Our samples are restricted to non-Hispanic whites over the age of 70 years old that live in the community or in nursing homes in 2016. This provides a study sample of 5330 participants in the HRS and 3147 participants in ELSA. We restrict our sample to non-Hispanic whites to ensure estimates are comparable across countries. Summary statistics of both the raw and selected samples are displayed in No study participants were involved in setting the research question or outcome measures, nor were they involved in any other area of the design, implementation and analysis of the study. There are no direct plans to disseminate the results of the research to study participants.et al estimated separate ordered probit models in the ADAMS subsample for self-respondents and proxy-respondents to generate a predictive algorithm for cognitive status, based on the ADAMS diagnoses, for the whole HRS sample. The algorithm uses a range of variables including demographic information, ADLs, IADLs, TICS questionnaire as well as the change in these variables across waves.et al algorithm is asked of self-respondents and proxy-respondents in both HRS and ELSA. Summary statistics for a variety of predictors are displayed in The HRS included a detailed clinical substudy  of 856 sample members aged 70+ who completed an in-depth in-home assessment of cognitive status conducted by experienced teams at the Duke University Dementia Epidemiology Research Center who diagnosed each participant as normal, cognitively impaired but not demented or demented.et al’s predictive algorithm to estimate the probably of dementia for those in the HRS sample in 2016 and extended the prediction to the ELSA sample. The algorithm predicts the probability of dementia in the following year; therefore, we predicted dementia prevalence in 2017. Hurd et al’s predictive algorithm has been shown to have an accuracy (percentage correctly classified as demented or non-demented) of 94%, sensitivity of 65% and a specificity of 98% in the estimation sample.We applied Hurd Non-response for people unable or unwilling to participate in the survey is important when attempting to estimate dementia prevalence across the population. While attrition exists in both surveys, it is unlikely to significantly affect our estimates since among older ELSA and HRS respondents, there is no statistically significant correlation between attrition and prior health or the SES indicators of education, income and wealth.18We considered four measures of SES: income; education; wealth and non-housing wealth. Income is measured as current household income from all sources. For education, we used total years of schooling. Wealth is measured as the sum of all household reported savings, stocks, bonds, business wealth, other assets and the value of housing assets  after financial debt and mortgage debt has been subtracted. Non-housing wealth is the same measure as wealth but excludes housing assets and mortgage debt and therefore measures wealth that can be more easily converted to cash. Wealth and non-housing wealth are both measured from 4 years prior to minimise reverse causality, as medical expenses associated with dementia are high and may run down wealth.We created a pooled dataset of the two surveys. In our statistical analysis, we used HRS and ELSA sampling weights to adjust for non-response and for the sampling design of the surveys. To make both within country estimates along the SES gradient and cross-country estimates directly comparable, estimates were age-gender standardised to the English population aged over 70 in 2016 using direct standardisation, categorising the population into 10 groups: five age bands  by gender. We estimated the prevalence of dementia in each country, their difference and compared the prevalence along the four SES gradients. For each estimate presented, we computed the corresponding 95% CI, and for any differences we computed the corresponding p values. For each SES factor, as well as estimating the age-gender standardised prevalence along the gradient, we calculated the Relative Index of Inequality (RII) and Slope Index of Inequality (SII) using generalised linear models  with logarithmic and identity link functions, respectively. The RII can be interpreted as the relative likelihood of dementia prevalence of those in the lowest SES group compared with those in the highest, and the SII can be interpreted as the absolute effect on dementia probability of moving from the lowest SES group to the highest.Next, we attempted to understand the potential drivers of these gradients and the differences in the gradients across countries. We extended the analysis to account for cardiometabolic diseases  and behaviours  as dementia risk factors.In the Education has also been shown to be a risk factor for dementia. In our main analysis, we exclude ethnic minorities, who have higher dementia prevalence and comprise a larger share of the USA than the English population. Including minorities increased the estimated difference across countries, from 1.43 pp to 2.42 pp, as can be seen in the Using nationally representative samples of older individuals from England and the USA and applying the same algorithmic procedure to predict dementia in both samples, we showed that in both the USA and England dementia is more prevalent among the disadvantaged, and the SES gradient of dementia is steeper in the USA. The steeper gradient in the USA is largely driven by those in the lowest decile. In both countries, most of the SES gradient disappeared when we controlled for past health related factors, although prevalence for those in lowest income decile in the USA remained disproportionately high. If the lowest income decile is excluded from our sample the difference in dementia prevalence across the countries is statistically insignificant, and the remaining SES gradient of dementia is remarkably similar across countries.While poorer individuals face a higher burden of dementia in both England and the USA, the extremely poor in the USA face a disproportionately high burden of dementia. Controlling for past health-related factors can explain some, but not all, of the cross-country difference. It can explain up to around one third of the difference for those in the lowest income decile. While past health factors such as adiposity and smoking are correlated with dementia, those in the lowest income decile in the USA do not smoke more or have higher body mass indexes (BMIs) than their English counterparts. Therefore, this cannot explain their disproportionately higher prevalence of dementia. Education also cannot explain the difference, as the US population is more educated at every income decile, and in fact the educational difference masks some of the underlying dementia risk difference between countries.Adding minorities increased estimated dementia prevalence, especially in the USA, because dementia prevalence is higher among minorities, who comprise a higher share of the USA than the English population. This fits with prior research which showed dementia prevalence is higher for non-whites and Hispanics.Previous studies have shown cross-country variation in dementia prevalence. However, substantial heterogeneity in case-ascertainment methods across countries and studies makes interpreting any observed differences difficult. We believe this is the first study to compare dementia prevalence in England and the USA using the exact same measure of dementia, thus overcoming previous difficulties in making comparisons across the two countries due differences in diagnostic practices and case definitions. We also compared the SES gradient of dementia in both countries. While some studies have shown in both England and the USA those with lower education and less wealth have been found to have higher rates of dementia,We showed that risk factors for dementia such as cardiometabolic diseases, psychiatric conditions, high BMI, smoking have similar affects across countries. Accounting for these risk factors removes most of the SES gradient for both countries, but disproportionately high prevalence remains for the most disadvantaged in the USA.Much research has shown that low-income Americans are more likely to be in poor health and die younger than their high-income counterparts.While risk factors contribute to higher prevalence among those who are more disadvantaged, those in the USA appear to have an undue burden that is caused by risk factors for which we cannot account. One possible explanation is differential access to healthcare. The NHS provides broadly equitable care according to education in the older population after accounting for health status.The implications of our results are that interventions designed to attempt to prevent dementia should be targeted towards the most disadvantaged. This is especially true in the USA. As yet, we are unable to advocate specific measures as we do not yet understand the specific nature of disadvantage in respect to dementia risk.This study has a strong design. Results are directly comparable across England and the USA. The same predictive algorithm was applied to both countries, addressing the problem of heterogeneity in case ascertainment which has affected the literature.This study had three limitations. First, we do not ascertain dementia directly, but predict cases using a common battery of measures in ELSA and HRS. Importantly, Hurd’s prediction algorithm has high accuracy and although our case definition lacks a clinical point of reference in England, it is based on a detailed clinical substudy in the USA.Given the large social and economic costs of dementia, there is great value in understanding the scope and burden of dementia in the population along the SES gradient. This study indicates that more disadvantaged individuals face a higher burden of dementia and that the poorest individuals in the USA face a disproportionately high burden. The high burden faced by these individuals can be partly but not fully explained by past health factors. We lacked data on other important possible contributing factors such as habitual drug use. Further research is needed to fully understand this issue using data from multiple sources.