Nasolacrimal duct obstruction (NLDO) is the most common cause of childhood epiphora. It is managed conservatively in the first year of life, after which surgical treatment is classically based on a stepwise paradigm of probing, intubation, and dacryocystorhinostomy. This systematic review aims to present the current role of intubation in the management of children with NLDO requiring surgical intervention. A search for English-language articles from the electronic databases PubMed, SCOPUS, and the COCHRANE library was conducted over a period of five months in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook. The following keywords were used to aid retrieval: stents, children, lacrimal intubation, endoscopic dacryocystorhinostomy, external dacryocystorhinostomy, NLDO, dacryocystitis, congenital, acquired. The primary outcome was defined as the success of the intervention, determined by resolution of symptoms and patency of the lacrimal anatomy confirmed by the fluorescein dye disappearance test or syringing. Secondary outcomes included the presence of complications. A total of 144 articles were identified; of these, 35 fulfilled the study criteria. The majority of the included studies involved lacrimal intubation alone, followed by intubation as an adjunctive procedure to balloon dacryoplasty and dacryocystorhinostomy. The overall success rate of these procedures ranged from 41.1% to 100%. Post-operative complications were reported in 65.7% of the included studies. Lacrimal intubation was most commonly performed as a primary procedure in children with NLDO, with high success rates. The main complication was stent dislodgement. There is lack of evidence regarding the benefit of intubation over probing as primary treatment of congenital NLDO. In the absence of high-quality evidence, the decision of whether to perform lacrimal intubation in children with NLDO requiring surgical intervention depends on clinical judgement and other low-level evidence, such as observational non-randomised trials. Nasolacrimal duct obstruction (NLDO) is the most common cause of childhood epiphora . Failed The surgical treatment of NLDO in children is classically based on a stepwise paradigm, with probing as the primary procedure, followed by balloon catheter dilation . IntubatThe search was conducted over a period of 5 months (November 2018 to March 2019) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  and the Articles were included in the systematic review if they fulfilled the following eligibility criteria: (1) prospective comparative design , cohort study), retrospective with comparative group design , retrospective or prospective non-comparative design ; (2) included participants were less than 18 years of age; (3) intubation was part of the management of NLDO. Articles were excluded if they were (1) case reports; (2) abstract only studies; (3) published in a language other than English.The primary outcome was defined as the success of the intervention, determined by the resolution of symptoms and the patency of the lacrimal anatomy confirmed by the fluorescein dye disappearance test, syringing or irrigation of the nasolacrimal duct. The secondary outcome was the presence of complications.The authors selected the studies according to the predetermined inclusion and exclusion criteria for this systematic review. This was done by reading the abstracts and/or the full articles. A standardised data extraction form was developed by the authors and used in the present study. The variables extracted from the studies included study location (country), number of patients, age, gender, intervention procedure, duration of tube removal, duration of follow up, overall successful outcome, and post-operative complications. Data extraction from the included studies was done by two authors independently. Any discrepancy between the two authors with respect to the data extracted were discussed. When disagreements remained, a third author was consulted for his/her opinion and decision.The quality assessment of the included studies was conducted by using the Effective Public Health Practice Project (EPHPP) checklist . The EPHA total of 144 articles were identified from the electronic databases. One hundred and twenty- eight articles remained after duplicates were removed. Seventy-nine articles were excluded after screening the titles and abstract as they did not meet the review criteria. Of the remaining 49 articles, data extraction was done by two authors independently; 14 articles that included adult samples and did not report subgroup analysis result for children samples below 16 years old were excluded. A total of 35 studies which fulfilled the selection criteria were included in the review see . From thA total of 2953 patients were pooled. The total number of patients for each study ranged from 4 to 635 patients. The mean age of patients ranged from 15 months to 11 years old. All studies involved the use of silicone stents. The majority of the included studies involved lacrimal intubation , with or without a comparative group; followed by intubation as an adjunctive procedure to extDCR (2 studies), EDCR (1 study), both extDCR and EDCR (1 study), and balloon dacryoplasty (1 study). The duration of the stent placements varied, while the average follow-up after removal of stent ranged from 9 weeks to 40 months. A meta-analysis was not performed due to the heterogeneity of all the included studies. Hence, meaningful interpretation of the study outcomes in the included studies required expert discussion and clinical judgement. The two main outcomes, percentage of success and presence of complications, are narratively described in Using the EPHPP global rating decision tool, four studies were assessed as being of moderate quality and 31 of weak quality see . Most ofThe management of children with epiphora is challenging, not only because of the miniaturized and variable anatomy of the lacrimal drainage pathways, but also because of the lack of high quality evidence regarding the optimal treatment of NLDO in children. Probing, which involves pushing a metal wire through the punctum, canaliculi, lacrimal sac, and nasolacrimal duct into the nose, is the standard of care for congenital NLDO. Although probing is successful in uncomplicated obstructions of the distal nasolacrimal duct , which cMost of the studies reviewed involved only lacrimal intubation, which generally had high success rates. Two RCTs compared stenting with other interventions for NLDO in children. Elsawaby et al. found no statistically significant difference in success rates between stenting and probing as a primary treatment for patients with congenital NLDO aged 6 months to 36 months . UnfortuTwo types of intubation were evaluated in the studies assessed; intubation using monocanalicular versus bicanalicular stents. The monocanalicular stent passes through a single canaliculus to the lacrimal sac and NLD, whereas the bicanalicular stent courses through both canaliculi into the sac and nasal cavity, after which the ends are tied in a loop inside the nasal cavity. Using a monocanalicular or bicanalicular stent had no statistically significant effect on outcome ,23, althThe rationale for intubation is that the stent may maintain patency of the newly-created lacrimal drainage passage by preventing the formation of granulation-related obstruction . The latAlthough there is a paucity of histopathological evidence of the effect of stenting in children, comparison of lacrimal sac biopsies in adults with and without silicone stents has not demonstrated any significant differences in mucosal histopathology . The durAnother downside of intubation is that stent-related complications are not uncommon . The mosThis systematic review observed that lacrimal intubation is most commonly performed as a primary procedure in children with congenital NLDO, with good outcome. It is preferred over probing alone in complex NLDO ,59,60. UThis systematic review identified only two RCTs evaluating the benefit of stenting over other surgical modalities in the management of children with NLDO. In the absence of high-quality evidence, the decision of whether to perform lacrimal intubation in children with NLDO requiring surgical intervention depends on clinical judgement and other low-level evidence, such as observational non-randomised trials.


A total of 31 patients underwent carotid endarterectomy and the ex vivo carotid plaques were imaged with OCT. Optical parameter, texture features and relative position of pixels were extracted within the region of interest and then used to quantify the tissue characterization of plaque components. The potential of individual and combined feature set to discriminate tissue components was quantified using sensitivity, specificity, accuracy. The results show there was a lower classification accuracy in the calcified tissue than the fibrous tissue and lipid tissue. The pixel-wise classification accuracy obtained by the developed method, to characterize the fibrous, calcified and lipid tissue by comparing with histology, were 80.0, 62.0, and 83.1, respectively. The developed algorithm was capable of characterizing plaque components with an excellent accuracy using the combined feature set.There is a need to develop a validated algorithm for plaque characterization which can help to facilitate the standardization of optical coherence tomography (OCT) image interpretation of plaque morphology, and improve the efficiency and accuracy in the application of OCT imaging for the quantitative assessment of plaque vulnerability. In this study, a machine learning algorithm was implemented for characterization of atherosclerotic plaque components by intravascular OCT using  Rupture of vulnerable atherosclerotic plaques is the leading cause of stroke and myocardial infarction . These sIt is now well established that plaque components and morphology are the main factors in the determination of plaque vulnerability , b. Plaqex vivo validation on the developed imaging processing methods is the other obstacle in this area.ex vivo carotid plaques.This study was designed to characterize and identify the fibrous, calcified and lipid tissues based on the expert annotation using histology images. In the present study, we used optical parameters, texture features combined with relative position of pixels to analyze and delineate plaque components in OCT images. Validation algorithm was performed by comparing these results with those of corresponding histological sections of the ex vivo OCT imaging and histology analysis. All participants provided a written informed consent prior to the enrollment and the study protocol was approved by the institutional ethics committee.In this study, 31 patients with a high-grade (>70%) carotid stenosis scheduled for carotid endarterectomy (CEA) from October 2015 to December 2018 were included. The dissected specimens were used for both TM catheter . The OCT system had high image resolutions of ∼15 μm, approximately 10 times finer than conventional intravascular ultrasound. Scan parameters were set as 100 frames/s, 54,000 A-scans/s, pullback speed of 20 mm/s, pullback length of ∼54.2 mm  . More deAfter imaging, each carotid plaque tissue was cut into 1 cm serial transverse segments. Each embedded segment was marked in the same order with the corresponding OCT pullback and was serially sectioned into slices of 4 μm transverse sections, with a 40 μm interval perpendicular to the longitudinal axis of the artery. Sections were mounted on the slide glass substrates and then stained with Hematoxylin and Eosin (H&E), Masson’s trichrome, Oil Red O to show the structural and morphology information within the plaque sample. The gross morphological features of OCT images such as lumen size and shape, wall size and shape, plaque configuration, as well as calcific plaques were used to adjust the cross-sectional orientation of the slices. Manual co-registration of the OCT images and the digitized histological slices was performed by two experts. The carotid bifurcation and the narrowest lumen (maximum stenosis) were used as the reference points of matching the histology slices and OCT images. The challenge is that the thickness of OCT imaging and histology slices was different. Every 0.1 cm plaque specimen could cover 5 OCT images in one pullback and 250 consecutive histology slices. We were able to use both ends of the plaque samples as additional registration points to co-register the OCT imaging with the histology slices.The images were annotated by the experts using ImageJ software , accordiAlthough the expert performed the annotation, the decision to delineate various tissue map was varying degree subjective and thus prone to analyst variability. To better annotation OCT images, another analyst is necessary to test the reproducibility. To determine reproducibility of annotation results, the intraclass correlation coefficient (ICC) with 95% confidence interval (CI) was calculated to measure the level of agreement between two measurements.Id(r) > can be modeled using a single scattering model according to the Lambert-Beer law  is a result of scattering and absorption. However, only scattering can be considered because the contribution of tissue absorption is very low at the near infrared wavelengths used in OCT , z0is the position of the beam waist and zR is the Rayleigh length. While Here zC is the center of the scan, and zW is the half width of the roll-off function  is linearized by logarithmic transformation:t and constant parameter log(I0) were calculated using a linear least-square fit to the OCT A-lines for different layers and for different positions of the individual layers by an optimization process.The attenuation coefficient μTexture features were extracted from the training set and the testing set images in order to be used for the classification of the plaque tissues. Texture refers to the spatial interrelationships and arrangement of the basic elements of an image. In the study, several texture features were selected as follows:First order statistics (FOS) textures are directly related to the gray tone distribution of the pixel intensity and ignore inter-pixel correlations. In the paper, four parameters including mean value, standard deviation, skewness and kurtosis were extracted directly from the image. More details can be found in reference .Gray level co-occurrence matrix (GLCM) is a powerful statistical tool for texture analysis, which is a tabulation of how often different combinations of pixel brightness values (gray levels) occur in an image . In thisNeighborhood gray tone difference matrix (NGTDM) corresponds to the visual properties of the texture . The folFractal dimension (FD) is an index for characterizing the fractal patterns or sets by quantifying their complexity as a ratio of the change in detail to the change in scale . In thisx and y coordinate of each pixel). This RP features were used in combination with other feature sets during the experiment because of their natural and essential characterization. The optical parameters were one-dimension information extracted by nonlinear fit, the texture feature sets (the four groups) were two-dimension features based on the local neighborhood operations, the sixth set was relative position of pixels (RP) (the Ntree (number of trees to grow) and Mtry (number of variables randomly sampled at each node). Each decision tree is independently produced and each node is split by the parameter Mtry. By growing the forest up to another parameter Ntree, the algorithm creates trees that have a high variance and a low bias. RF becomes increasingly popular in similar medical image classification applications because of its computational efficiency for large training data, ability to handle multiclass classification.To handle the large training set, the random forest (RF) algorithm was selected . RF is a®, Natick, MA, United States): image processingTM and Parallel ComputingTM toolboxes.Annotation regions were compared on a pixel-wise basis with the results of the RF classifier. The performances of the RF classification methods were compared based on the following model accuracy measures: sensitivity, specificity, accuracy (ACC) . In ordeR2 = 0.99). The fit lines had slopes of 1.02, and y-intercepts of 0.06 mm2 . The occurrence of the misclassification is mainly due to the blurring of the boundaries of the three main components. Although the literature indicates that the calcified region has a clear boundary, it is difficult to annotate an accurate tissue map in the pixel-wise way. In addition, more feature parameters may be needed to interpret the heterogeneity of OCT tissue components and further distinguish the plaque components.Recently, CNN have shown remarkable success in medical image processing tasks such as disease classification , tumor setc.Until now, most research has shown that an atherosclerotic plaque with a lipid or necrotic core and a thin fibrous cap is associated with an increased risk of plaque rupture and thrombus formation, resulting in an acute coronary event or progression of atherosclerosis . Therefoex vivo CEA plaque samples, the OCT imaging of the various ex vivo plaque components is in agreement with those reported for in vivo studies  and histology (4 μm). The limitation can be overcome by undertaking continuous histological slide preparation of vessel segments. Second, the data set annotation was performed according to the plaque components and shape of histology image using manual analysis by expert image readers as the ground truth. It is well known that the manual analysis of OCT images tends to cause inter-observer variability and intra-observer variability, and thus resulting in a relatively large deviation. Despite this, it is important to note that some studies have shown the influence of intra-observer on manual image analysis was scarce . FinallyIn this study, the combination of the optical parameters and the texture features of OCT images were extracted and used for characterization of carotid atherosclerotic tissue types. The algorithm was validated against histology slices, which were the “gold standard” as the evaluation criteria. This study shows that the developed approach can provide an effective tool for OCT-based plaque vulnerability assessment. Although the statistical results still need to be further improved before the computer-aided automatic segmentation method is applied in routine clinical practice, the fundamental research filled the gap in the quantification and characterization of atherosclerotic tissue types from OCT imaging.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by IEC for Clinical Research of Zhongda Hospital, Affiliated to Southeast University. The patients/participants provided their written informed consent to participate in this study.CH and ZhiL presented the concept and design of the work. CH performed lumen segmentation, the texture feature extraction and RF computations and drafted the manuscript. YH performed the optical parameters extraction. CH, JW, and YY analyzed the data. JW, ZhoL, and ZhiL provided suggestion and editing assistance. ZhiL critically revised the manuscript. All the authors approved the final version and made substantial contributions to this work.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.


The global abrupt progression of the COVID-19 pandemic may disrupt critical life-saving services such as routine immunization (RI), thus increasing the susceptibility of countries to outbreaks of vaccine-preventable diseases (VPDs). Being endemic to several infectious diseases, Lebanon might be at increased risk of outbreaks as the utilization of RI services might have deteriorated due to the pandemic and the country’s political unrest following the October 2019 uprising. The aim of this study was to assess the changes in the utilization of RI services in both the public and private sectors following the COVID-19 pandemic.A self-administered cross-sectional survey was completed electronically, in April 2020, by 345 private pediatricians who are registered in professional associations of physicians in Lebanon and provide immunization services at their clinics. Means of the reported percentages of decrease in the utilization of vaccination services by pediatricians were calculated. As for the public sector, an examination of the monthly differences in the number of administered vaccine doses in addition to their respective percentages of change was performed. Adjustment for the distribution of RI services between the sectors was performed to calculate the national decrease rate.The utilization of vaccination services at the national level decreased by 31%. In the private sector, immunization services provision diminished by 46.9% mainly between February and April 2020. The highest decrease rates were observed for oral poliovirus vaccine (OPV) and hepatitis A, followed by measles and pneumococcal conjugate vaccines. The number of vaccine doses administered in the public sector decreased by 20%. The most prominent reductions were detected for the OPV and measles vaccines, and during October 2019 and March 2020.The substantial decrease in the utilization of RI as a result of the COVID-19 pandemic requires public health interventions to prevent future outbreaks of VPDs. The global abrupt progression of the COVID-19 pandemic may increase the risk of disruption of critical life-saving services such as routine immunization (RI) due to the diversion of the resources and efforts of healthcare systems towards supporting the response to the pandemic, in addition to the alterations in health-seeking behaviors as a result of social distancing requirements and public hesitancy. Interruption of vaccination services will increase the susceptibility of countries to outbreaks of vaccine-preventable diseases (VPDs) including measles and polio among others, as large pockets of unvaccinated infants and young children emerge .COVID-19 is the not the first infectious disease to be tackled while facing challenges to prevent outbreaks of others . In 2019Experience from prior outbreaks occurring following considerable deteriorations in immunization rates has highlighted the urgency of maintaining RI services. For instance, in Samoa, 83 deaths within 3 months were attributed to a measles outbreak following a 50% drop in vaccination coverage . Likewisth, 2020, interim guidance for immunization services during the COVID-19 pandemic. The guidance recommended sustainment of RI programs while preserving the safety of health workers and populations, temporary suspension of mass immunization campaigns based on individual risk-benefit assessments, and the establishment of innovative strategies to assess immunity gaps and track unvaccinated children , practicing medicine in Lebanon and providing RI services. Given the likelihood of low response rates, an exhaustive sampling design was adopted in this study. The availability of practicing physicians’ databases from the two orders of physicians including their detailed contact information enabled the deployment of this sampling design. Physicians with incorrect or unavailable contact information, or with duplicated membership were excluded.A survey questionnaire was developed by Connecting Research to Development (CRD) public health team and subsequently reviewed and approved by national experts . The queSurveys of pediatricians not providing RI services were excluded from the study. Descriptive statistics with proportions, and frequency distributions were conducted for categorical variables. Means of the reported percentages of decrease in the utilization of vaccination services by pediatricians were calculated. Data were analyzed using SPSS version 21.Adherence to ethical guidelines was ensured throughout the research process. The study was approved by the Institutional Review Board (IRB) at Transforming Research to Development (TRD) as per reference number TRDIRB03020. Voluntary participation and withdrawal were granted as the survey questionnaire was self-administered online. The scope, aim and ethical considerations of the survey were rigorously explained in the introductory section and consent was obtained by answering the question “Do you agree to participate in this study?” Confidentiality was strictly applied during all study procedures. Surveys were anonymous and did not comprise any variable jeopardizing the identity of the participant or their patients.Out of the 1,317 pediatricians who were invited to participate in the survey, 384 participants responded. However, the answers of 345 pediatricians, who reported providing RI services, were included in the analysis, yielding a response rate of 26.2%.77.4% of physicians reported an overall decrease in the utilization of RI services between October 2019 and April 2020 as compared to the same period last year. Specifically, more than two-third of the respondents indicated a deterioration in the utilization rates of PCV vaccine (82.0%) and hepatitis A vaccine (79.8%) followed by DPT-containing vaccines (73.0%), measles/MMR vaccines (70.8%) and IPV vaccine (69.7%). The confinement period extending between February and April 2020 witnessed the most significant decrease rate in immunization services provision according to 87.6% of respondents .On average, survey respondents estimated an overall decline in the utilization of RI by 46.9% in the private sector. Percent change reduction rates in the provision of specific vaccines ranged between 46% and 58% with the highest being reported for OPV (57.5%) and hepatitis A vaccines (57.2%) followed by PCV (53.3%), measles, (53.3%) and MMR vaccines (49.9%). The lowest percent decrease rate among the investigated vaccines was attributed to DPT-containing vaccines (46.3%) .Analysis results of data from the public sector came in the same direction as those detected in the private sector. A negative difference of 71,567 doses was detected in the number of administered vaccines’ doses between October 2019 and March 2020 as compared to the same period last year, reflecting a 20% decrease in the utilization of routine vaccination services in the public sector. Among vaccines administered in the public sector, the highest negative percentage change was observed in measles vaccines (-38%) followed by OPV (-28%) .The examination of fluctuations in the monthly number of administered doses between the current and previous year revealed a negative difference throughout the study period. March witnessed the highest decrease in the total number of administered doses in the public sector (-47%) followed by October (-31%). In March, the substantial reduction was observed in measles vaccines whereby the number of administered doses declined by 73%. The decrease was slightly less prominent for OPV, Pentavalent, IPV and PCV and ranging from 40% to 44% .Assessing the decrease in the utilization of RI services at the national level requires adjustment for the distribution of routine vaccination services between the public and private sectors. This was accomplished based on data from the Expanded Program on Immunization (EPI) Cluster survey indicating that around 60% of vaccination services are provided in the public sector and the rest in the private sector . AdjustmThis study assessed the changes in the utilization of RI services in both the public and private sectors in Lebanon between October 2019 and April 2020 as compared to the same period last year. Findings revealed a 31% decrease in the utilization of vaccination services at the national level. In the private sector, immunization services provision diminished to almost half with the greatest reduction being reported during the confinement period extending between February and April 2020. Utilization rates of all the investigated vaccines have dropped by almost half. The highest decrease rates were observed for OPV, hepatitis A, followed by measles and PCV-containing vaccines. The assessment of fluctuations in the number of vaccine doses administered in the public sector yielded a similar pattern, however with a lower decrease rate. The most prominent reductions were detected for the OPV and measles vaccines, and during October 2019 and March 2020.th, 2020 and assessed the changes in the number of vaccine orders and the number of doses administered in the united states between January and April 2019 as proxy-indicators of vaccine usage. Report results were consistent with our study findings as noticeable reductions in the number of non-influenza vaccine doses, specifically measles-containing vaccines, were observed for children below 2 years of age. The report also highlighted the declaration of a national emergency as a start point for deterioration in vaccine usage. Similar outcomes were observed in our study as the highest decrease rates in the utilization of immunization services were witnessed after the declaration of the general mobilization plan during the month of March 2020 in the public sector, and during the confinement period extending between February and April 2020 for the private sector [th, 2019 uprising coupled with road blockages and economic crisis. The road blockade were eased during December 2019 and thus private physicians regained their activities while the public sector was slower to recover as the trust of people in the State and all public services were deeply impacted by the news of corruption and inefficiency that accompanied the uprise.To our knowledge, this study was the first to assess the impact of the COVID-19 pandemic on the utilization of vaccination services in Lebanon and the Middle East and North Africa (MENA) region. A similar study was conducted in England to assess the early impact of COVID-19 on routine childhood vaccination by April 2020 . AdditioAs per our study findings, the utilization of immunization services has diminished by 31% at the national level between October 2019 and April 2020. The obtained results were comparable to those observed in previous epidemics such as Ebola. A study by Barden -O’Fallon et al. evaluating Ebola-related implications on newborn and child health service delivery and utilization in Guinea in both private and public facilities has revealed a 31% reduction in outpatient visits with child health services including immunization being the most affected by the Ebola epidemic . ConcernWhen it comes to results on the provision of vaccines from the national immunization calendar, OPV and measles vaccines have witnessed the highest reductions in both the public and private sectors. Besides the CDC report mentioned earlier, there are currently no studies in the literature assessing the changes in the utilization of specific vaccines during the COVID-19 pandemic. Nevertheless, decrease rates for measles vaccine detected in our study (-53.3% in the private sector and -38% in the public sector) were greater than those stated in a report from the Ebola epidemic indicating a 20% decrease in measles coverage during December 2014 as compared to the previous year . The incThe main strength of our study is first its originality since it is the only study to assess the impact of COVID-19 pandemic on the utilization of RI services in Lebanon and the MENA region. In addition, vaccination data were collected from all sectors operating in the immunization field in Lebanon, hence rendering the results more reflective of the global vaccine usage in the country. A methodological strength point worth mentioning is the adjustment for the distribution of routine vaccination services between the public and private sectors when calculating the national decrease rate in the utilization of immunization services which further increases the accuracy of the reported rate.Conversely, several limitations that merits discussion were detected in our study. To begin with, vaccine usage was assessed based on vaccine administration which is a proxy-indicator of vaccination coverage, rather than the latter itself. This was accomplished for ease of access to information and due to the impracticality of conducting coverage studies in pandemic circumstances. Moreover, assessing the utilization of vaccination services in the private sector was associated with several limitations. First, a relatively low survey response rate (26%) was identified, questioning the representativeness of the sample. Another limitation might be related to the methodology of our study where decrease rates in vaccine usage were determined by pediatricians based on subjective estimations as computerized patient records are rarely available. Hence, an overestimation of the observed rates is conceivable, and both recall and information biases are introduced. On the other hand, vaccination figures from the public sector are deemed of greater objectivity since they were extracted from electronic reports communicated on a regular basis by public immunization facilities with the ministry of public health.In summary, our results suggest a substantial decrease in the utilization of RI services in both the public and private sectors as a result of the COVID-19 pandemic. Among vaccines of the national immunization calendar, the provision of OPV and measles vaccines was mostly affected during the studied period in both sectors, whereas hepatitis A vaccine witnessed the most significant decrease in usage among vaccines administered only in the private sector.Our study findings highlight the need for various stakeholders in the immunization field to implement interventions aiming at enhancing RI in all sectors, as well as raising awareness among the general public and healthcare providers on the importance of sustaining immunization services’ provision during the COVID-19 pandemic especially with the potential burden associated with occurrence of outbreaks of VPDs on the economy in a country struggling to overcome its financial crisis.The evidence generated through this research can be the milestone for projecting the occurrence of future outbreaks of VPDs in Lebanon, thus increasing the preparedness levels of public health authorities to prevent and respond to any potential infectious diseases’ crisis.S1 File(DOCX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.


The achievement of high-efficiency oil/water separation has huge implications for protecting environment and reducing economic losses, but there is still a great challenge. Currently, most artificial oil/water separating materials are fabricated through complex preparation process, resulting in the very high cost of separation. In this paper, we present a simple and low-cost method to achieve oil/water separation by using the underwater superoleophobic materials that already exist in our life or nature. Taking filter paper and zeolite layer as examples, we show the inherent porous microstructures of these materials. Such porous microstructures endow filter paper and zeolite layer with strong ability to absorb water and the underwater superoleophobicity. Based on the porous feature and underwater superoleophobicity, the pre-wetted filter paper and zeolite layer can be used to effectively separate the mixture of water and oil, with great separation capacity. The existing materials  with both porous microstructure and underwater superoleophobicity in our life or nature are green and low-cost, and can be easily obtained. Such advantages allow those materials to potentially solve the pollution problems caused by the discharge of industrial oily wastewater and the oil-spill accidents. Frequent oil spills severely threaten the marine ecosystems and the health of coastal inhabitants. For example, the famous Gulf of Mexico oil spill which occurred in 2010 released 200 million gallons of crude oil onto the sea. The discharge of industrial oily wastewater is continuously increasing year by year with the process of industrialization. In our daily life, the kitchen also produces a large amount of oil/water mixtures every day. The oil-spill accidents and the oily wastewater discharges not only cause huge economic losses but also lead to serious water pollution and other ecological and environmental problems  and repel oil droplets in water . The features of porous microstructure and the underwater superoleophobicity endow the filter paper and the zeolite layer with the great ability of oil/water separation. When the oil/water mixture was poured onto the pre-wetted filter paper or zeolite layer, only water could pass through these materials, while oil was maintained above the separating materials, achieving high-efficiency oil/water separation.Filter paper and zeolite layer are selected as the examples to separate the mixture of water and oil. Such common materials already exist in our life or nature. In this experiment, filter paper and zeolite particles are purchased directly through Internet shopping. The zeolite particles are previously cleaned with water before measurement.A simple oil/water separation device was designed based on the filter paper and zeolite particles. A plastic bottle (such as drink bottle) was removed its bottom half, and the rest top half was placed upside down. The bottle cap was drilled by a mechanical drill to form many holes with the diameter of 1–2 mm. A piece of metal mesh (300 mesh size) was placed inside the porous bottle cap as the support and also to prevent the separating materials from being lost. Then, the separating materials (the filter paper or the zeolite layer with the thickness of ~1 cm) were put onto the mesh, with tightening the cap. Before pouring the mixture of oil (petroleum ether) and water (V:V = 1:1) into the designed separating device, the filter paper and zeolite layer need be pre-wetted by a small amount of water. To distinguish oil and water, water was dyed by methylene blue and oil was dyed by Oil Red O.The surface microstructures of the filter paper and zeolite layer were analyzed by a scanning electron microscope . The static contact angle and dynamic sliding angle were measured via a contact-angle measurement . Deionized water and 1,2-dichloroethane were used as the main detecting water and oil.Filter paper is a typical porous membrane in our life and is mainly made up of cotton fibers. 4 tetrahedral and AlO4 tetrahedral. Zeolite particles are able to stack up into material with rich gaps. Zeolite in nature is a kind of porous silicoaluminate mineral with water-containing cage structure. Its skeleton is SiOω, can be obtained from Equation (1):Surface wettability is mainly governed by the chemical composition and surface morphology of a solid substrate  and the Young's CA, and r is the roughness factor . According to the Wenzel equation, hierarchical rough microstructures increase the real surface area of these materials, so the hydrophilicity is enhanced to superhydrophilicity  in our life or in nature have inherent microscale porous structure and micro/nanoscale hierarchical rough surface texture. By combining with the inherent hydrophilic chemical composition, these materials showed strong water-absorption ability as well as the superhydrophilicity in air, without any further treatment. When the filter paper and the zeolite layer were dipped into water and an oil droplet was put on their surfaces, the oil droplet was at the underwater Cassie wetting state, resulting in the underwater superoleophobicity of these porous materials. The ingenious combination of porous feature and underwater superoleophobicity endows the filter paper and the zeolite layer with the great ability of oil/water separation. When the mixture of water and oil was poured onto the pre-wetted filter paper or zeolite layer, only water was able to penetrate through these materials, while oil was maintained above the separating materials. Therefore, the mixture was successfully separated with high efficiency. The measured separation efficiency for the filter paper was 96.02% and that for the zeolite layer was 97.23%. Similar to the filter paper and zeolite layer, there are a mass of existing materials in our life or in nature having both inherent porous microstructures and underwater superoleophobicity, which can be potentially used as the separating materials for oil/water mixtures. Such existing materials are natural, green, and low-cost materials, and can be easily obtained, showing great advantages in solving the pollution problems caused by the discharge of industrial oily wastewater and the oil-spill accidents.The original contributions presented in the study are included in the article/HB and JY designed the experiments and wrote the manuscript. FC directed and supervised the research. QY and XH contributed toward significant discussions and revised the paper.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.


Chronic endometritis is an inflammation in the inner layer of uterine mucosa, with or without an infectious process, which affects the animal's fertility but not its general health. A variety of treatments has been adopted over the years but to date, no effective cures have been able to renew the injured tissue. Since the defects in the fetal-maternal communication are caused by degenerative changes due to chronic endometrial inflammation, our working hypothesis was a new approach to this disease by the regenerative medicine using amniotic derived microvesicles (MVs) for their anti-inflammatory and regenerative effects. The MVs are responsible for horizontal transfer of genetic materials, including microRNA (miRNAs) that are involved in paracrine communication between origin cells and target cells. Thus, intrauterine MV infusion may be beneficial in degenerative chronic endometritis and in the fetal–maternal talk. The selected mare was an 11-year-old Friesian, with a history of failed pregnancies despite numerous insemination attempts. Punctual and evident heats characterized the reproductive history, but no insemination attempts had been made for many years. The first (failed) insemination was when the mare was 9-years-old. In the next two reproductive seasons, other attempts were made at regular intervals but none was successful. After a final insemination attempt using a stallion of proven fertility, the collection of an 8-day old embryo suggested that the mare was affected by implantation failure related to endometritis. The mare was treated with two cycles of intrauterine administration of amniotic-derived MVs. The success of the intrauterine administration of MVs was demonstrated by an improvement in the classification of endometritis and in a successful artificial insemination (AI) with implantation of an embryo, as detected at day 14 and with a pregnancy that is still ongoing. Probably, MVs were able to restore the injured endometrium and re-establish the proper communication for a successful embryo implantation. Defects in the endometrial tissue could hinder this passage of information and lead to reduced fertility  insemination was when the mare was 9-years-old. In the next two reproductive seasons, eight other attempts (four times in each season) both naturally and artificially were made but none was successful. Gynecological examination and instrumental investigations were normal and there was no relevant history. Visual examination of external genitalia focused on the perineal conformation to assess the level between the anus and vulva, paying attention to previous lacerations or Caslick interventions. In addition, a manual check of the integrity of the vestibular-vaginal sphincter was performed to exclude secondary infections due to pneumovagina or fecal contamination. The inspection of vagina and cervix was performed with a sterile tubular speculum to detect alterations, such as purulent drainage, cervical lesions, or urine stagnation that might indicate endometritis. The vestibule-vaginal features were also observed to detect the stage of the estrus cycle. A slight increase in tone and consistency of the uterus and, particularly of the cervix was detected. Lastly, endometrium biopsies were performed with a pair of 60 cm alligator forceps, taking a sample from the dorsal wall of the uterine body. The aim of the biopsy was to assess the starting condition of the mare and the results revealed a degenerative chronic category IIB endometritis. The histological sample showed a continuous endometrial epithelium composed of columnar cells sometimes raised in folds. Infiltration of lymphocytes and plasma cells was observed in the stratum compactum and spongiosum  and as pTo support the assumption that the failed inseminations were related to the pre-implantation phase and to exclude issues with conception, an insemination test (ninth attempt of insemination) was performed with the cryopreserved semen of a stallion of proven fertility. The collection of an 8-day old embryo confirmed that the issue was due to an inadequate fetal–maternal communication that would hinder a successful implantation.in vitro cultured of amniotic derived cells (AMCs). This protocol was approved by the Ethical Committee of the University of Milan (OPBA_118_2017). The AMCs were obtained at birth from the allanto-amniotic membrane of three broodmares. Samples were transported at 4°C in NaCl 0.9% solution supplemented with 4 mg/mL di amphotericin B (Euroclone), 100 UI/mL di penicillin, 100 mg/mL di streptomycin (Euroclone), and handled in laboratory within 12 h. The isolation method was previously described by Lange Consiglio et al.  and AI was performed using cryopreserved sperm. No inflammatory fluid retention was observed in the uterine lumen after this intervention, similarly to what was detected during all the ultrasound clinical evaluation performed in the past. On the 14th day after insemination, the first ultrasound check identified an embryonic vesicle and, thus, the presence of a pregnancy that is still ongoing . The marWhen mesenchymal stromal cells (MSCs) were first used in regenerative medicine, their therapeutic properties were attributed to a direct action of differentiation at the site of damage but it has since been shown that the main mechanism of action is paracrine signaling . This coIn recent years, the regenerative mechanism of MSCs has been focused on MV action responsible for horizontal transfer of cytoplasmic content including miRNAs . In genein vitro by AMCs.This is the first report discussing the case of a mare affected by chronic degenerative endometritis and with a history of failed inseminations, which appeared to have been resolved following intrauterine administration of MVs secreted In this mare, infertility was caused by a defect in the implantation phase, and not related to conception, as suggested by the ability to form an 8-day embryo during pre-treatment tests. The success of the intrauterine administration of MVs was demonstrated by post-treatment histologic results that showed an improvement in the classification of endometritis. At the end of treatment, the mare was classified as almost normal, and 14 day after AI an embryo was successfully detected by ultrasound and the pregnancy is still ongoing.Of course, any of the MVs cargo may have contributed to an improvement in the pathological picture of this mare, but our attention has been mainly focused on miRNAs that are non-coding RNA molecules of about 22 nucleotides in length that induce gene silencing through translation repression or degradation of the target molecule . In a coin vitro studies . All procedures were conducted following standard veterinary practice and in accordance with 2010/63 EU directive on animal protection. The informed client consent was obtained for collection placenta at term of horse pregnancies and for horse treatments.FC and AL-C designed the study. AL-C and AI performed AMC isolation and MV preparation. FC and FF enrolled animal, performed ultrasonography evaluation, biopsies, MV administration. AI pregnancy diagnosis. CC and PR performed biopsy analyses. AL-C and FC evaluated the results of biopsies. AL-C wrote the manuscript. All co-authors provided useful comment on the manuscript.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.


We also present a series of special articles and reviews that highlight our understanding of cellular mechanisms, biomarkers to tract disease pathology, the diversity of mouse models for NMDs, the importance of high-quality preclinical studies and data validation, and the pitfalls of successfully moving a potential therapeutic strategy to the clinic. In this Editorial, we summarize the highlights of these articles and place their findings in the broader context of the NMD research field.Neuromuscular disorders (NMDs) encompass a diverse group of genetic diseases characterized by loss of muscle functionality. Despite extensive efforts to develop therapies, no curative treatment exists for any of the NMDs. For multiple disorders, however, therapeutic strategies are currently being tested in clinical settings, and the first successful treatments have now entered clinical practice . Successful clinical translation depends on the quality and translatability of preclinical findings and on the predictive value of the experimental models used in their initial development. This Special Issue of Disease Models & Mechanisms has a particular focus on translational research for NMDs. The collection includes original research focusing on advances in the development of novel  Summary: This Editorial summarizes the highlights of DMM's Special Issue ‘A Guide to Using Neuromuscular Disease Models for Basic and Preclinical Studies’. Maaike van PuttenAnnemieke Aartsma-RusJames J. DowlingNeuromuscular diseases (NMDs) are a broad and heterogeneous collection of disorders that involve dysfunctionality of the peripheral nerves and/or muscles. For the majority of these disorders, the genetic defect has been known for decades and a vast amount of knowledge on their aetiology, epidemiology and pathophysiology is available . AlthougThe predictive value of preclinical studies is determined by the availability of cell and animal models that can accurately recapitulate disease aspects. Initial compound selection requires cell models with corresponding genetic defects. Currently, tools such as induced pluripotent stem cells (iPSCs) and gene-editing technologies such as clustered regularly interspaced short palindromic repeats (CRISPR)/Cas9 have respectively enabled the rapid production of suitable cell and animal models . The genTo many researchers in the NMD field, science is personal. Therefore, we open this issue with exclusive ‘A Model for Life’ interviews with Elizabeth McNally and Louis Kunkel, two pioneers in the field who have dedicated their careers to improving our understanding of NMD biology and translating it into clinically viable interventions. Elizabeth talks about the important role of targetable genetic modifiers and about her passion for team sports , whereasWe also present a series of ‘First Person’ interviews with the early-career researchers who were the first authors of research articles in this special issue. In these, a new generation of scientists tells us the stories behind their papers, the key challenges of NMD research and their future career plans.This issue features two ‘Special Articles’ that, from vastly different perspectives, highlight the steps necessary to successfully translate fundamental insights into viable clinical approaches. The first, by Belinda Cowling and Leen Thielemans , provideNext, guest editors Annemieke Aartsma-Rus and Maaike van Putten discuss the unique advantages and challenges of developing humanized mouse models for neuromuscular disease. In a field in which defined genetic causes are the backbone and foundation of disease understanding and pathogenesis, and mutation-specific forms of therapies hold great therapeutic potential, mouse models that carry the human sequence and recapitulate the key features of human disease represent a viable testing platform .http://dmm.biologists.org/content/13/2/dmm042192/F1.poster.jpg), visualizes the processes discussed in the article.A new ‘At a Glance’ article presents the cellular mechanisms that govern the growth and regeneration of skeletal muscle, and highlights the defects in satellite cell function that give rise to muscular dystrophies . The accImproved understanding of the biological processes governing muscle development and regeneration can point to both therapeutic windows and valuable biomarkers for tracking disease progression and response to treatment. Although researchers can use various model systems to address these questions, the mouse remains the most popular model animal. van Putten and colleagues have collated a comprehensive table summarizing mouse models of various muscular dystrophies , which wConcluding this section, members of the TREAT-NMD Advisory Committee for Therapeutics review their own experiences in providing detailed feedback on clinical proposals for neuromuscular diseases submitted by researchers in both academia and industry . BecauseVMA21 gene  patient carrying a mutation in the copper transporter ATP7A . The derA21 gene . They stSGCG gene. Mice consequently suffer from a severe muscular dystrophy. The authors show, for the first time, that the disrupted reading frame of the Sgcg gene could be restored with antisense oligonucleotide exon skipping, leading to production of internally truncated but functional γ-sarcoglycan protein upon local administration. Cordero-Sanchez et al. generated a knock-in mouse model (KI-STIMI115F) that carries a clinically relevant mutation in one of the two calcium-sensing EF-hand motifs of STIM1  recapitulate the genetic and pathological hallmarks found in NMD patients is of great importance for the execution of more in-depth preclinical research. They not only allow for pharmacokinetic, pharmacodynamic and safety studies, but also enable assessments of a therapeutic compound's effects on muscle quality and functionality. This Special Issue contains two articles describing novel mouse models. Demonbreun et al. utilized CRISPR/Cas9 gene editing to generate a mouse model for limb-girdle muscular dystrophy type 2C . This 52of STIM1 . Gain-ofTo allow successful preclinical development of therapeutic strategies, it is important to have access to extensive data on the natural disease progression of animal models, a broader understanding of the disease pathology, and robust outcome measures that can be used to assess treatment efficacy. Zdenka Ellederová’s group neatly characterized pathology of the brain and nerves of a minipig model for Huntington's disease . Their imdx mouse model of DMD and showed that the absence of full-length dystrophin alters the firing rate and pattern of Purkinje cells , experience alterations in their microbiome and expansion and activation of immune cells prior to developing motor function deficits  during zebrafish development, and thereby increased our understanding of the interplay between different RyR isoforms and of the pathological mechanisms underlying the heterogeneous set of phenotypes in patients with RYR1 mutations . The secathology . UnfortuAside from the excellent research published in this Special Issue, DMM has long had the privilege of featuring a number of excellent research and review-type articles in the field of neuromuscular disorders. Here, we highlight the most-read ones, and apologize to the authors of the articles we couldn't feature due to space restraints.DMD mutation in a Russian patient , in which we will continue to collate exciting review, research and resource articles. We hope you enjoy reading these freely accessible articles.This Special Issue also launches an ongoing subject collection (The Special Issue nicely highlights the amazing advances in the neuromuscular field in recent years related to pathomechanistic understanding and therapy development. There is an increasing amount of novel cell and animal models available, even for some of the rarest NMDs, which will allow for further characterization of the disease pathology and hopefully facilitate the development of novel therapeutic strategies. It has become clear that insights into the natural history of the individual NMDs, standardization of outcome measures and validation of research findings are of utmost importance to de-risk translation of therapeutic efficacy from model systems to patients. This change in perspective could move the NMD field forward and might result in better selection of candidate compounds and eventually a higher success rate in clinical trials for these devastating disorders.http://dmm.biologists.org/collection/neuromuscular.This article is part of a special collection ‘A Guide to Using Neuromuscular Disease Models for Basic and Preclinical Studies’, which was launched in a dedicated issue guest edited by Annemieke Aartsma-Rus, Maaike van Putten and James Dowling. See related articles in this collection at


The strength of goal-oriented behaviors is regulated by midbrain dopamine neurons. Dysfunctions of dopaminergic circuits are observed in drug addiction and obsessive-compulsive disorder. Compulsive behavior is a feature that both disorders share, which is associated to a heightened dopamine neurotransmission. The activity of midbrain dopamine neurons is principally regulated by the homeostatic action of dopamine through D2 receptors (D2R) that decrease the firing of neurons as well as dopamine synthesis and release. Dopamine transmission is also regulated by heterologous neurotransmitter systems such as the kappa opioid system, among others. Much of our current knowledge of the kappa opioid system and its influence on dopamine transmission comes from preclinical animal models of brain diseases. In 1988, using cerebral microdialysis, it was shown that the acute activation of the Kappa Opioid Receptors (KOR) decreases synaptic levels of dopamine in the striatum. This inhibitory effect of KOR opposes to the facilitating influence of drugs of abuse on dopamine release, leading to the proposition of the use of KOR agonists as pharmacological therapy for compulsive drug intake. Surprisingly, 30 years later, KOR antagonists are instead proposed to treat drug addiction. What may have happened during these years that generated this drastic change of paradigm? The collected evidence suggested that the effect of KOR on synaptic dopamine levels is complex, depending on the frequency of KOR activation and timing with other incoming stimuli to dopamine neurons, as well as sex and species differences. Conversely to its acute effect, chronic KOR activation seems to facilitate dopamine neurotransmission and dopamine-mediated behaviors. The opposing actions exerted by acute versus chronic KOR activation have been associated with an initial aversive and a delayed rewarding effect, during the exposure to drugs of abuse. Compulsive behaviors induced by repeated activation of D2R are also potentiated by the sustained co-activation of KOR, which correlates with decreased synaptic levels of dopamine and sensitized D2R. Thus, the time-dependent activation of KOR impacts directly on dopamine levels affecting the tuning of motivated behaviors. This review analyzes the contribution of the kappa opioid system to the dopaminergic correlates of compulsive behaviors. Compulsion is the impossibility of self-stopping to execute a habitual action with known outcome, despite adverse consequences . Compulssubstantia nigra (SN) and ventral tegmental area (VTA), which target the dorsal and ventral tiers of the striatum, respectively. Dopamine neurons that project to the ventral striatum or nucleus accumbens (NAc) have been traditionally related to goal-oriented behaviors, whereas dopamine neurons that project to the dorsal striatum have been associated with habits acquisition (One possible mechanism leading to compulsive behavior is framed within the incentive-sensitization theory of addiction which is that an amplified motivation (“wanting”) for the drug develops during addiction without developing an amplified pleasurable (“liking”) effect . Endurinuisition .Sensitization of the reward/motivation circuit is observed in rodents as the gradual increase in locomotor activity induced by repeated administration of a potentially addictive drug fixed dose . LocomotThe kappa opioid system is one of the most preponderant systems controlling dopamine transmission in the reward/motivation circuit. Evidence shows that kappa-opioid transmission opposes to the effects of dopamine; the acute activation of kappa opioid receptors (KORs) counteracts the locomotor activity induced by psychostimulants . ConversThe thorough analysis carried out recently shows that the effect of the kappa-opioid system on dopaminergic transmission is complex: it depends on the dopamine pathway involved , and on KORs are Gi/o protein-coupled receptors highly expressed in the midbrain dopamine system . These rSeveral experimental approaches show that the activation of KORs inhibits dopamine release. The acute activation of KORs by a systemic injection or the local infusion of agonists decreases the extracellular levels of dopamine in the NAc  and dors, in vitro and in vivo functional data suggests that KORs modify dopamine extracellular levels by modulating the activity of DAT. For instance, the activation of KORs in EM4 cells that co-express KORs and DAT, lead to an increased uptake of dopamine measured by voltammetry  it decreases locomotor activity, while at higher doses (>0.5 mg/kg), it increments. . These eAt the beginning of the 90's, Szechtman and Eilam reported that along with locomotor sensitization, rats developed a stereotyped behavior, which is reinforced with each administration of quinpirole . Today, in vivo consists of tonic and burst firing  and high (postsynaptic) doses of quinpirole. U69593 changed the hypolocomotor effect of a presynaptic dose of quinpirole to hyperlocomotion and enhanced the hyperlocomotor effect of a postsynaptic dose of quinpirole . Co-actiThe crosstalk between D2Rs and KORs is complex and it seems to depend on whether the activation of both receptors is coincident or temporally separated. Anatomical data indicate that the crosstalk between D2Rs and KORs can occur presynaptically in axons and soma of dopamine neurons, as well as postsynaptically in MSNs of the striatum. Although it does not rule out a role for KORs located on axons of other neurochemical systems, the anatomical data strongly points to a direct role of KORs regulating D2Rs. Either acute or repeated, the activation of KORs decreases the inhibitory D2Rs function on dopamine neurons. Electrophysiology studies showed that the acute activation of KOR in dopamine neurons of the VTA and SN inhibits D2R-mediated inhibitory postsynaptic current, an effect mediated by pre and postsynaptic mechanisms as KOR decreases dopamine release and dynorphin blocks the inhibitory effect of bath applied dopamine . NeurochA recent study shows that KOR activation in the VTA mediates compulsive behavior measured as behavioral inhibition and marble burying , reinforRemarkably, KOR was found in MSNs of the NAc , thus inClinical studies have shown sex differences in compulsive behavior including compulsive drug seeking. An earlier onset of OCD symptoms is observed in men compared with women , with woin vitro experiments showed that estradiol plus progesterone restore amphetamine-induced dopamine release from striatal tissue obtained of ovariectomized female rats (Lately, pre-clinical evidence has strongly highlighted the neurobiological bases underpinning the sex differences in drug abuse observed in clinical studies . Early oale rats . More reale rats . These sale rats .The regulation of KOR on dopamine extracellular levels also shows sex differences . Using iAlthough a facilitation in psychostimulant induced dopamine release is observed in female compared to male rats, sex differences in the dopamine mechanisms underlying amphetamine locomotor sensitization have not been fully elucidated . The repHow do KORs modulate dopamine signaling to elaborate motivated behaviors and when does it result in a sensitized compulsive behavior? Anatomical data shows that KORs are exquisitely positioned to control the synaptic activity of midbrain dopamine neurons. Functional data indicate that KORs control DAT and D2R functioning as well as dopamine neurons firing rate. Initial evidence showing that the acute activation of KORs decreases dopamine release induced by drugs of abuse has been complemented with data indicating that the repeated activation of KOR facilitates dopamine release and compulsive drug-seeking. Dopamine signaling balance direct and indirect output pathways from striatal areas (AE, MA, and JF contributed to the conception of the manuscript. AE and JF wrote the first draft of the manuscript with input from MA. MA and JC contributed to the critical review and editing of the manuscript. All the authors approved it for publication.The work of the authors cited in this review has been supported by FONDECYT grant numbers: 1110352 and 1150200 to MA; 1141088 to JF; DIPOG grant 391340281 to JF; FONDECYT Postdoctoral fellow 3170497 to JC and 3190843 to AE.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.The handling editor is currently organizing a Research Topic with one of the authors JF, and confirms the absence of any other collaboration.


The aim of this study was to conduct histological analysis of a human tooth resected with the periodontal insertion apparatus intact following treatment using biologically oriented preparation technique (BOPT). This descriptive histological dento-periodontal study used an anterior tooth extracted with the surrounding periodontal tissues intact, following prosthetic restoration with BOPT. The sample patient was recruited from among those attending the Department of Dental Medicine at the Faculty of Medicine and Dentistry, University of Valencia (Spain). Eight serial sections of the restored tooth were processed. The relative location and histological characteristics of the cemented prosthetic crown, the dental tissues of the tooth prepared by BOPT technique, and the periodontal tissues were analyzed. Structural analysis of the neoformed junctional epithelium showed that the number of layers decrease apically until there was a single row of cells perfectly adhered to the acellular cementum, and beneath the epithelium a connective tissue evidently free from inflammation. The tissues of the neoformed periodontium  presented histologic normality. Biologically oriented preparation technique is a reliable alternative to conventional horizontal finish lines. Key words:Vertical preparation, prosthetic cementoenamel junction (PCEJ), finish line, BOPT, crown. Tooth preparation technique without finish line, also known as biologically oriented preparation technique (BOPT), is a protocol in which the emergence of the tooth crown is eliminated above its cemento-enamel junction (CEJ) using diamond burs . This maResearch conducted to date vouches for good periodontal behavior around teeth prepared by BOPT, and for the stability of peri-coronal soft tissues . In BOPTThe aim of this study was to conduct histological analysis of a human tooth resected with the periodontal insertion apparatus intact following treatment using BOPT.Materials and MethodsThis descriptive histological dento-periodontal study used an anterior tooth extracted with the surrounding periodontal tissues intact, following prosthetic restoration with BOPT. The University of Valencia Ethics Committee for Research Involving Human Subjects approved the study protocol . The study was carried out at the Department of Pathology, Faculty of Medicine and Dentistry, University of Valencia (Spain).The criteria for obtaining the sample were as follows: Inclusion criteria: Age >18 years; good general health; non-smoker or smoker consuming <10 cigarettes per day; patient presenting an anterior maxillary or mandibular tooth with poor prosthetic prognosis requiring extraction; patient willing to provide informed consent to take part in the study. Exclusion criteria: active periodontal disease around the tooth, unmanaged diabetes or any other systemic disease that could compromise surgery; in treatment by bisphosphonates, pregnant or lactating women.The sample patient was recruited from among those attending the Department of Dental Medicine at the Faculty of Medicine and Dentistry, University of Valencia (Spain). The female patient chosen was aged 63 years and presented a single upper right central incisor. This tooth was chosen for its poor restorative prognosis and severe atrophy of the alveolar ridge in the edentulous area which, together with the extrusion of the peri-dental tissues produced a large discrepancy, making prosthodontic treatment difficult. The treatment plan consisted of a first phase of tooth extraction and pre-prosthetic bone remodeling surgery. It was decided that this case would provide an ideal specimen for the purposes of the present study as it was possible, through the use of therapeutic strategies, to extract the cervical part of the periodontal tissue together with the tooth.Following Helsinki Declaration guidelines for experiments involving human subjects, we explained the surgical treatment to the patient, providing full details of the procedure, and of the need to return for later check-ups. Via an informed consent form, the patient accepted a 16 weeks delay before treatment; during this time a full coverage crown would be placed with BOPT technique in order to study the soft tissues responses after BOPT. All personal data and medical notes related to treatment were subject to complete confidentiality by the staff involved in the study, in accord with Spanish legislation.As in any treatment involving a fixed prosthesis, the first step is to carry out intra and extraoral examination taking clinical notes, photographic records, and then to fabricate study models set in a semi-adjustable articulator. After diagnosis and treatment planning, the models set in the articulator were sent to the laboratory technician who fabricated a provisional crown in self-polymerizing acrylic resin .For dental preparation without finish line, the drilling system and adaptation procedure for placing the full coverage provisional crown were as described by Agustín -4, with After this stage, a definitive complete coverage crown was fabricated from lithium disilicate  using ceramic injection Fig. . It was Piezosurgery; Mectron Dental) and with saline irrigation applying a force vector perpendicular to the root axis 3 mm apical of the gingival margin. A horizontal cut was made resecting the gingiva, vestibular bone crest, cervical area of the root, cortical bone and palatine gingiva  were resected. To obtain the specimen, a cut was made with a piezoelectric instrument at low speed , for 24 h each. The sample was sequentially embedded at room temperature in 40 mL of the following solutions: methyl methacrylate (MM) for 15 days, then MM containing benzoyl peroxide (1 g/100 mL) for 3 days, and finally in MM containing poly (methyl methacrylate)  and benzoyl peroxide. Polymerization at room temperature took several days. Using a diamond wire saw , the sample was sectioned transversally in vestibular-palatine direction in 800 μm slices. Sample slices were glued on poly methyl methacrylate slides, wet ground to a thickness of 80 μm and polished using a LaboPol-21 system (Struers) and SiC foils and further polished with diamond paste of decreasing grain sizes. The slides were sequentially stained with Stevenel’s blue and van Gieson’s picro-fuchsin following the procedure described by Maniatopoulos Eight serial sections of the restored tooth were processed. The relative location and histological characteristics of the cemented prosthetic crown, the dental tissues of the tooth prepared by BOPT technique, and the periodontal tissues were analyzed. In particular, newly formed tissues following restoration – sulcular and junctional epithelia and gingival ligament – were studied in detail Fig. .As a result of the BOPT process, the absence of enamel and the presence of normal coronal dentin without histological alterations were evident. The partial removal of acellular cementum by BOPT technique did not modify the structure of the underlying root dentin Figs. ,6.Towards the apical zone, the structure of the unaltered cementum and the compact bone of the alveolar crest were normal. The periodontal ligament embedded in cementum and periodontal bone showed a normal amount and spatial organization of collagen bundles, cell density and vascularization, with no signs of inflammation.Attached gingiva was covered by a keratinized stratified squamous epithelium lining a normal connective tissue without any signs of inflammation. The free gingiva, gingival margin and sulcular epithelium regenerated following BOPT also presented a normal histological structure. The connective tissue beneath showed a slightly increased number of defensive cells but without apparent signs of inflammation. The organization and spatial distribution of the collagen bundles corresponding to the dento-gingival and dento-periosteal fascicles were normal.Lastly, the newly formed junctional epithelium attached to the new dentin-cementum surface created after BOPT reached from the bottom of the gingival sulcus to a variable height depending on the serial section studied. In some sections a short and wider junctional epithelium was observed, far from the alveolar crest. In other sections the epithelial attachment was much longer, lining the dental surface close to the alveolar bone crest. This was newly formed epithelium, and the number of layers decreased apically, ending with a single row of cells firmly attached to the non-carved acellular cementum Fig. .When teeth are restored with fixed prostheses, the location of the gingival margin has always been a subject of debate within the field of dentistry -8. Some The type of dental finish line has also been widely studied in prosthodontic research during the last 35 years or more. Pardo , in 1982Following the destructuring of periodontal tissue caused by dental preparation and shaping, designed to simulate the anatomy of the natural tooth, healing and physiological maturation of the periodontal tissues takes place in such a way that these adapt to the contours of the prosthesis’ cervical emergence.In the present study, structural analysis of the neoformed junctional epithelium showed that the number of layers decrease apically until there was a single row of cells perfectly adhered to the acellular cementum, and beneath the epithelium a connective tissue evidently free from inflammation. In particular, the tissues of the neoformed periodontium  presented histologic normality.Biologically oriented preparation technique is a reliable alternative to conventional horizontal finish lines. After BOPT, in which gingival tissues are modeled in response to the shape of the prosthetic emergence, periodontal protection tissues, especially neoformed insertion tissue, are structurally equivalent to normal periodontal tissue, ensuring a healthy environment free from inflammation.


Trabectedin, gemcitabine‐docetaxel, and pazopanib are also used in cases of advanced cancer.The efficacy of adjuvant/neoadjuvant chemotherapy and radiotherapy focused on histological UPS or prostate sarcomas has not been demonstrated. Therefore, surgery remains the cornerstone of treatment in nonmetastatic UPS. In this report, the tumor recurred at the front of the rectum despite the resected margin having been negative. Moreover, the occurrence of multiple liver metastases is more common in rectal than prostate cancers. I am interested in a potential causal relationship between transrectal biopsy and tumor recurrence in prostate sarcomas. The biopsy tract and scar should be removed at the time of definitive surgery to prevent recurrence from tumor seeding in STS.The author declares no conflict of interest.


Thrombophilia-screen tests are specialised haemostasis tests that are affected by numerous unique patient variables including the presence of acute thrombosis, the concomitant use of medication and patient demographics. Complete information on the request form is therefore crucial for the haematological pathologist to make patient-specific interpretation of patients’ results.To assess the completeness of thrombophilia-screen test request forms and determine the impact of provision of incomplete information, on the interpretive comments generated by reporting haematological pathologists. To assess the impact of an educational session given to clinicians on the importance of providing all the relevant information on the request forms.Two retrospective audits, each covering 3 months, were performed to evaluate the completeness of demographic and clinical information on thrombophilia-screen request forms and its impact on the quality of the interpretive comments before and after an educational intervention.One hundred and seventy-one request forms were included in the first audit and 146 in the second audit. The first audit revealed that all 171 thrombophilia-screen request forms had complete patient demographic information but none had clinical information. Haematological pathologists only made generic comments which could not be applied to a specific patient. The second audit, conducted after a physician educational session, did not reveal any improvement in the clinical information provision by the test-ordering physicians. This was reportedly due to the lack of space on the request form. The interpretive comments therefore remained generic and not patient-specific.Physicians’ failure to provide relevant clinical information made it impossible for pathologists to make patient-specific interpretation of the results. A single physician education session did not change the practice, reportedly due to the inappropriate design of the test request form. Further studies are required to investigate the impact of an improved request form and the planned electronic test requesting. Thrombophilia-screen tests are requested in a select group of patients presenting with venous thromboembolism (VTE) to predict the likelihood of recurrence of thrombosis and to decide on the duration of anticoagulation therapy. Anticoagulation treatment increases the risk of bleeding therefore careful assessment is needed before intense, extended or life-long treatment is instituted. On the opposite pole, insufficient therapy predisposes to recurrent thrombosis. AnticoagPatient demographics including age and gender influence the normal reference ranges of various parameters included on the thrombophilia-screen. Timing of sample collection and immediate delivery to the laboratory are imperative for thrombophilia-screen tests. Other variables to consider include underlying infections, liver disease, renal dysfunction, obstetric history, the presence of acute thrombosis and additional concomitant medication.in vitro phenomenon of prolonged phospholipid-dependent clotting time due to acquired autoantibodies. These autoantibodies target the phospholipid-binding proteins of the cell membrane resulting in a paradoxical risk of thrombosis in vivo.[The lupus anticoagulants (LAC) is an  in vivo. LAC test in vivo.–7Levels of the natural anticoagulants, which form part of the thrombophilia-screen, including Protein S (PS), Protein C (PC), and Antithrombin (AT), can be falsely low during the acute phase of thrombosis. Exposure to OC, HRT and anticoagulant medications also impact the natural anticoagulants and should be taken into account when interpreting test results.,8 The scAnticoagulation therapy can vary from a few months to lifelong therapy, depending on the patients’ clinical presentation taken in combination with thrombophilia-screen test results. Furthermore, the intensity of the anticoagulation varies depending on the patients’ unique attributes.,9 The prStudies evaluating the adequacy of information provided on request forms revealed that the clinical information is frequently inadequate.–14Interventions are necessary to improve the provision of demographic and clinical data upon requesting thrombophilia screening tests. The intervention strategies include test-requesting clinician education, strict sample rejection policies, improving the request form design and using electronic laboratory test requesting systems.,15–17The aim of this study is to investigate the completeness of information provided on thrombophilia-screen request forms and to assess the impact of any incomplete information on the interpretive comments of test results. Furthermore, the impact of a single educational session for clinicians is determined by re-assessing the information provided on the request forms after the educational intervention. To our knowledge, this is the first study conducted in a coagulation laboratory in South Africa that focused on the impact of insufficient clinical data on the interpretative comments of thrombophilia-screens before and after the education of requesting physicians on the importance of providing all relevant information on the request forms.The study was conducted at the National Health Laboratory Service (NHLS) Coagulation laboratory at Tygerberg Hospital (TBH), a 1 384 bed multidisciplinary tertiary care academic hospital in the Western Cape province of South Africa. TBH is the main teaching hospital for the University of Stellenbosch’s Faculty of Medicine and Health Sciences. The Coagulation laboratory renders services to TBH and non-Tygerberg hospitals (NTBH). NTBH are surrounding tertiary- and district-hospitals as well as out-patient clinics, which refer patients and/or samples for testing to TBH.This was a quasi-experimental, pre- and post-intervention study in which two retrospective audits were conducted. The audits analysed the completeness of the information provided on thrombophilia-screen request forms received from TBH and NTBH. The initial audit assessed the completeness of the request forms over 3 months (01 July—30 September 2017). The second audit was performed one month after the educational session. It assessed the same information over 3 months (01 November 2017–31 January 2018). Only TBH physicians participated in the educational session, thus the NTBH arm was the control group.The following exclusion criteria applied:Requests only for genetic assays for Factor V Leiden and the Prothrombin 20210A mutations.Request forms referred from outside the Western Cape Province.Request for thrombophilia screening in individuals below the age of 18-years.More than 90% of the physicians responsible for ordering thrombophilia screens participated in the educational session which was carefully designed to deliver key messages regarding the reasons why the clinical and demographic information was required. The pre-analytical factors affecting the test results were explained. These factors included; the timing of the specimen drawing, the order of specimen tube drawing, the use of tourniquets, the impact of underfilling or overfilling of the specimen tubes, the specimen temperature and the time allowed between specimen draw and analysis. The effect of patient demographics and attributes such as the presence or absence of acute thrombosis at the time of testing, renal and liver disease, infection, pregnancy, and the concomitant use of anticoagulant and other medication, was explained. The impact of inadequate information on the pathologist’s ability to make a patient-specific interpretation of the results was emphasised. The educational session consisted of a 30 minute Microsoft PowerPoint® presentation by the principal investigator and 15 minutes of open discussion and questions.Provision of the following parameters on the request form was assessed;Patient demographics: name, surname, folder number, date of birth and gender.Hospital, clinic and/or ward information.Requesting physician information: name, speciality and contact details .Clinical information: presumptive clinical diagnosis, documented presence of acute thrombosis, anticoagulant therapy and other concomitant medications.Date and time of specimen collection.The impact of incomplete clinical information was measured by assessing the interpretive comment provided for abnormal results. If a generalised or generic comment was provided, the impact was considered significant. A generic comment in this study was defined as any comment that could not be applied to the specific patient. The impact of the education session was measured by comparing the information supplied on request forms referred from TBH, where the educational session was conducted, and NTBHs, where no educational session occurred.® software and the Statistical Package for the Social Sciences (SPSS) version 25 was used for data analysis. The Pearson’s chi-square test was used to compare categorical outcomes between sites, and between the pre- and post-intervention assessments at the same site. The odds of having complete data for each field on the form were estimated using multiple logistic regression analysis, with the site (TBH versus NTBH), time period  and the interaction between site and timing to indicate an intervention effect.Data was captured using Microsoft ExcelThe study was approved by the Ethics Committee of the University of Stellenbosch (project registration number HEA-2017-1494) and was performed according to the Helsinki Declaration (2000) guidelines. The request forms were collected retrospectively and a waiver of consent was obtained. Data was collected by a single investigator to maintain consistency and confidentiality. The data capture sheet included the different variables and whether the forms had the complete information or not. Patient confidentiality was maintained and patient identifying information was not included on the data capture sheet on which patients were identified by a study number only.Three hundred and sixty-six request forms were received (195 and 171 in the first and second audit periods respectively). Based on the exclusion criteria, 46 forms were excluded and 3 forms were not retrievable, leaving 317 forms (171 and 146 in the first audit and second audit periods respectively). In the first audit, 128 request forms were received from TBH and 43 from NTBH. In the second audit, 114 forms were from TBH and 32 were from NTBH.All forms from TBH and NTBH, pre- and post-educational intervention had patient demographics, which consisted of patient name, hospital folder number, date of birth and gender. This information was on the computer-generated sticker that was affixed to the request form. All request forms evaluated from TBH and NTBH, pre- and post-educational intervention had insufficient clinical information. Figs  and 2.The odds of completion of select variables in the post-education and control groups was compared using logistic regression analysis. There was no significant improvement in the intervention group in comparison to the control group, as shown by the non-statistically significant interaction term in the models below . The excIn the first audit, 38 (22%) and in the second audit 23 (16%) thrombophilia screens had abnormal test results. The interpretative comments provided by the haematopathologists were not customised for the specific patient but were generic. Examples of the generic comments that were provided are shown on Relevant clinical information including the presence of acute thrombosis at the time of specimen collection, family history of thrombosis, use of anticoagulation therapy or other medications at the time of testing was incomplete in almost all (98.4%) request forms pre- and post-intervention. The lack of inclusion of this information on the request forms rendered it impossible to assess the odds ratio and the p-value in these variables.All respondents in a sample of the post-education session TBH doctors revealed that the reason for not providing clinical information on the request form was that there was insufficient space on the form to enter the required information.The pre-analytical phase in laboratory testing includes procedures that are out of the control of the laboratory personal such as completion of request forms. Several This study found that the patient demographic data was the best-provided data on the request forms referred for thrombophilia-screen tests, which was in agreement with other studies.,12,19–21et al focused on the impact of incomplete information on laboratory request forms with regards to interpretive comments from pathologists. The authors concluded that the lack of clinical data can lead to an inappropriate assessment of thyroid function test results.[The essential clinical information necessary for appropriate interpretation of thrombophilia-screen test results was lacking on all request forms. This is consistent with many studies which established that clinical information is one of the least completed sections on the laboratory request form.–14 A Sou results.A similar previous study indicated that insufficient data on the laboratory request forms influenced the interpretive comment. In this Interpretation of thrombophilia-screen results takes into account the provisional diagnosis; the time elapsed after the thrombotic event, exposure to medication and patient age. In this Omission of test-requesting physician details impairs communication of critical laboratory results to the treating physician or ward staff and make it impossible for laboratory staff to request any further patient-specific information. In the fet al. showed that manually completed requesting doctor details can lead to insufficient, incorrect or illegible data on request forms and that the use of ink-stamps personalised with the name, unique doctor registration number and contact details improved the availability of this information on request forms.[Burnett L st forms.The time of specimen collection is important in coagulation-based thrombophilia-screen test analysis and analysis should ideally be performed within 4 hours of blood collection. In the first audit, the time of specimen collection was not stated in 30 (17.5%) request forms. These requests should ideally be rejected. Due to the magnitude of the problem, it was decided to accept the requests pending the systematic collection of data from this study. A comment pointing out the reasons for the need to state the collection time and the impact of its omission was made on the reports.et al. evaluated the effectiveness of clinician education on improving the practice of completing request forms. The study showed improvement after clinician education.[et al showed that a redesigned request form reduced the frequency of requesting inappropriate tests.[Studies have been performed to analyse the impact of remedial interventions on the adequate completion of laboratory request forms by clinicians.,15–17 I.ducation. However,ducation.,15 Baileet al. evaluated a manual compared to an electronic request form and concluded that the latter improved the quality of the information provided on the request forms.[A study conducted by Majed Al Dogether st forms. ElectronBased on the finding of this study we recommend a combination of regular educational events about the importance of proper completion of request forms and the implications of incomplete request forms in addition to other remedial measures. It is recommended that a new method of capturing the required information be designed. This should include a new format for the current request form, a separate request form for thrombophilia screening and electronic ordering.There was no formal question to establish the reason why pathologists only made generalised, generic interpretive comments due to the authors’ knowledge that it was impossible for patient-specific comments to be made without the relevant clinical information.The lack of relevant patient clinical information made it impossible for pathologists to provide clinically useful patient-specific interpretive comments on thrombophilia screening tests. A single educational event failed to improve the provision of such information and this was attributed to the poor design of the thrombophilia screening test request form . RecommeS1 Data(XLSX)Click here for additional data file.S1 Appendix(PDF)Click here for additional data file.S2 Appendix(PDF)Click here for additional data file.