The main goal of this study was to identify the moderating role of temperamental traits, as defined by Strelau’s Regulative Theory of Temperament (RTT), in explaining brain activity evoked by video stimuli of varying stimulatory value. fMRI scans were performed in a group of 61 young females in the luteal phase of the menstrual cycle. The validity of stimulus selection had been verified prior to the main study by collecting declarative measures of affective reactions, including valence, arousal, and basic emotions ratings. The choice of dynamic and complex video-stimuli allowed us to induce high levels of arousal effectively. Three categories of movies used in the experiment included neutral, low arousing, and highly arousing scenes. Movies classified into the last category depicted extreme-sport activities allowing us to confront the subjects with recordings potentially life-threatening situations. Results of the study revealed that activation of orbitofrontal cortex in highly arousing conditions is linked to the levels of activity, while traits of perseverance and emotional reactivity were negatively correlated with the BOLD signal in this structure. Low arousing movies evoked higher activation of the amygdala and left hippocampus in emotionally reactive subjects. Obtained results might be coherently interpreted in the light of RTT theory, therefore providing its first validation using functional brain imaging. From a historical perspective, temperament is one of the earliest theoretical constructs investigated by psychologists. Despite decades of theoretical and empirical developments, its core definition remained unchanged. Temperament is understood as a set of basic, biologically determined personality traits. Most influential theories of temperament include: Buss and Plomin Behavior Genetics-Oriented Model of Temperament , 1984, TIn the current study, we decided to use the Regulatory Theory of Temperament (RTT) proposed by Jan Strelau. According to this theory, temperament is a set of basic, primarily biologically determined and relatively stable personality traits, which apply to the formal characteristics of behavior. There are two types of temperamental characteristics described in RTT: energetic and temporal. Briskness  and perseverance [the tendency to continue and to repeat behavior after cessation of stimuli (situations) evoking this behavior] are classified as energetic traits. Sensory sensitivity , endurance  and activity  are considered temporal traits .Contrary to other theories of temperament (for example PEN), Strelau did not hypothesize about any specific neurophysiological mechanism responsible for traits manifestation. Nevertheless, he stated that behavioral activation plays a major role in reactions related to temperamental traits. As a consequence, the functional significance of temperament can be most clearly demonstrated when individuals are confronted with stressful situations or excessive environmental demands . FurtherThus, even though the biological processes underlying individual differences in temperament are postulated within the RTT, particular traits are not ascribed to specific mechanisms . FurtherOne of these studies , aimed aDespite the crucial role of biological bases postulated in all theories of temperament, neuroimaging studies are still struggling to identify neural processes underlying temperamental traits. The literature of fMRI studies focused on temperamental traits is broad, however, obtained results are often contradictory . Task-baCanli discoveries concerning affect-processing regions were further corroborated in other studies using static affective pictures e.g.,  and emotAll the results presented above determined our decision to use movie clips as the mean of eliciting emotional states in our subjects. Based on the premises of RTT, we assumed that finding neural correlates of temperamental traits should include conditions evoking the highest possible arousal levels. To achieve that goal we decided to present videos of people involved in extreme sport  activities. RTT states explicitly that temperament plays a regulative role in providing stimulation which suits individual needs . One of We used an experimental design in which movies differing in their arousing properties (extreme vs. low arousing sports vs. control movies) were shown to subjects in order to demonstrate the role of temperament in explaining patterns of brain activity. Based on the assumptions of RTT, we expected extreme sports to be appetitive stimuli for subjects with low emotional reactivity and high activity. In particular, we expected these traits to be correlated with increased activity of the reward system structures: nucleus accumbens, amygdala, and orbitofrontal cortex. On the other hand, the opposite pattern should be detectable in subjects with high emotional reactivity, as for this group, high levels of stimulation are aversive.Sixty-one right-handed female subjects (mean age: 23 ± 2.6) with no history of neurological or psychiatric disorders, participated in the study. Given the planned sample size, we decided to recruit participants of one sex only to avoid potential confounding effects that could not be effectively controlled. The decision to invite females was motivated by the fact that female samples are usually characterized by a larger proportion of high-reactiveness scores  and our Most of the subjects were college students. All participants gave their informed consent prior to the start of the experiment. A local research ethics committee at the SWPS University of Social Sciences and Humanities approved the experimental protocol of the study. Subjects received financial gratification in the amount of PLN 100 (approximately EUR 24).In addition, all participants were set up to enter the experiment in the MRI scanner during a specific phase of the menstrual cycle, which was the luteal phase, to prevent changes in the pattern of brain activity related to the differences in sex-hormones’ levels .Formal Characteristics of Behavior – Temperament Inventory  is a selFormal Characteristics of Behavior – Temperament Inventory was administered to the subjects before the fMRI procedure. The final sample of participants was selected from a larger pool of students to maximize the variance of the emotional reactivity and activity scores. The scores on all scales of FCB-TI were approximately normally distributed and followed the expected pattern of inter-correlations reported for the normative sample in the questionnaire handbook. Thanks to the demographic homogeneity of the study group, there was no need to normalize or transform obtained results; therefore, in all subsequent analyses, raw scores were used.1.The behavioral data acquisition was performed using a dedicated online platform developed by the Laboratory of Brain Imaging at Nencki InstituteThe behavioral procedure consisted of a presentation and rating of 18 short movies used in the fMRI experimental procedure . Movies were presented in pseudorandomized order. After each of them, the participant had to answer questions assessing the intensity of basic emotions , valence and arousal evoked by the stimulus . The exact duration of the procedure depended on the speed of participants’ reactions as the task was self-paced.Participants were asked to complete this part of the procedure at home (it was available online) not later than 1 week after the scanning session. To standardize the conditions, we instructed participants to provide all the ratings within one session and using a desktop computer or a laptop (not a mobile device). Valid results were obtained from 43 subjects .2. Ratings of individual movies were averaged for each subject and stimulus category  and submitted to univariate repeated measures ANOVA. This procedure was repeated for each of the seven rating scales. Post hoc tests with Bonferroni correction were used as follow-up analysis.Behavioral results were analyzed using Microsoft Excel and JAMOVI statistical packageThe experimental design  was base3. The aim of the control question was to ensure that the subject did not fall asleep. Each trial began with an empty gray screen (duration 1 s), which was a sign to prepare for watching the stimulus (movie). Then the 45-s movie was presented and after each movie participants were asked to close their eyes for 90 s when the measurement of the resting state activity was obtained (these results are not reported in this article). At the end of the resting state period, participants heard a sound signal, which prompted them to open their eyes and answer a control question (5 s), which came up on the screen . The answers were given with the right hand through the ResponsePad (NNL Response Grip)Every participant underwent a training procedure before the main experiment. The training allowed participants to get accustomed to the response pad used for the control questions and to learn to react to the sound signal indicating the end of the resting-state recording.Whole brain imaging was performed with a 3-Tesla MRI scanner  equipped with 32-channel phased array head coil. Head movements were minimized with cushions placed around the participants’ heads.*-weighted gradient echo planar imaging (EPI) sequence with the following parameters: time repetition = 1.100 ms; time echo = 28 ms; flip angle = 80°; matrix size = 96 × 96; field of view = 190 mm; in-plane resolution: 1.98 mm × 1.98 mm; and 48 axial slices, with 3 mm slice thickness with no gap between slices. Detailed anatomical data of the brain were acquired with T1-weighted  sequences with isotropic voxel size (1 mm × 1 mm × 1 mm). For each subject, the functional run consisted of 1226 volumes lasting 46 min (split into two parts).Functional data were acquired using a T2t-tests depicting the main effect of movies, rest and movies categories were computed for the whole group.Statistical Parametric Mapping  running on MATLAB 2012  was used for data processing and statistical analyses. First, functional images were motion corrected. Then, structural images from single subjects were coregistered to the mean functional image. High-dimensional Diffeomorphic Anatomical Registration through Exponentiated Lie Algebra (DARTEL) was used to create a group-specific template and flow fields based on segmented tissue from T1w images. The functional images were normalized using compositions of flow fields and group-specific template to a 2 mm isotropic voxel size. Finally, the normalized functional images were smoothed with a 5 mm isotropic Gaussian kernel. In the first-level statistical analysis, experimental runs for each subject were merged into a single model. All the experimental events were modeled and head movement parameters were entered as covariates into the design matrix. Movies, resting state and control question were modeled. All stimulus functions were convolved with the canonical hemodynamic response basis function (HRF). On the second-level analysis, p < 0.05 was applied. For each cluster, the main peak of activation with a corresponding t- and p-values, as well as the brain structure name, are provided in the tables.All the reported data were a family wise error (FWE) corrected for multiple comparisons at the voxel level and a significance threshold of 4. Due to the sparsity of data on correlates of temperamental differences our choice of studied structures was determined by existing literature on emotional processing and included: frontal and prefrontal areas  analysis. ROIs were defined using Automated Anatomical Labeling atlas (AAL)al areas , insula al areas , precuneal areas , structual areas . In the al areas  for everAnalysis of behavioral results confirmed the existence of the clear differences among the three categories of movies used in the study. A significant effect of movie-category was found for each dimension used in the rating procedure. Observed mean scores followed the expected pattern, in particular, extreme-sport movies evoked highest levels of arousal and fear. All the descriptive statistics, as well as details of ANOVA results, are available in The main purpose of the study was to use subjects’ individual scores in order to explore the role of temperament in explaining brain activation evoked by different categories of video-stimuli. However, for the sake of completeness, we start our analysis with examining the basic effects of resting and movie-watching as well as the differential effects of movie categories – regardless of the temperamental traits.To ensure that the manipulation of the movie content was effective, and systematically related not only to the behavioral ratings but also brain activation patterns, we run a series of contrasts comparing all pairs of video categories.The first contrast compared high arousing and neutral movies. It revealed widespread activations in areas responsible for the processing of emotional stimuli , visual perception  and parahippocampal gyrus. Detailed results are showed in In the second step, we contrasted high and low arousing movies. Results showed that viewing material depicting extreme sports was related to stronger activations in inferior parietal lobule and anterior cingulate cortex .Not surprisingly, the activations evoked by low arousing  movies were weaker than those observed in the first contrast. Significant activity was present in visual processing structures , middle frontal, and parahippocampal gyri .The relationship between the temperamental traits and brain activity while watching low and high arousing movies was explored using ROI analysis. It revealed a markedly different pattern of correlations depending on the stimulus category.For high arousing movies, we observed negative relationships of β values in the middle orbitofrontal gyrus with perseverance and emotional reactivity scale. A positive correlation was revealed for activity scale in the same brain area. Furthermore, the BOLD signal in the insula and hippocampus negative correlated with scores on endurance scale. Detailed results are presented in A similar analysis for low arousing movies revealed very interesting results for the emotional reactivity scale which correlated with the key structures of the limbic system: amygdala , hippocaBefore referring to the obtained results, we would like to underline two important novel aspects of our study. Firstly, it employed a new procedure aiming to reveal the neural correlates of emotional stimuli processing while controlling the stimulatory value of the videos presented during the fMRI session. That allowed us to identify brain-activity correlates of temperamental traits across varying arousal levels. As mentioned before, RTT states explicitly that temperament plays a regulative role in providing levels of stimulation suiting our individual needs . TogetheWe used an experimental design in which movies evoking varying levels of arousal were chosen in order to show the moderating role of temperament on brain activity. Our behavioral data confirmed that selected movie material differed significantly on the scales of basic emotions, valence, and arousal. As expected, the most arousing movies got the highest scores on arousal and fear scales. Surprisingly, this category of stimuli also scored highest on the happiness scale. The validity of stimulus selection was further confirmed by the results of the fMRI analysis. As expected, significant differences in brain activity were observed depending on the stimulative properties of the movies. All conducted contrasts comparing movie categories revealed expected results. The main effect of movies and rest showed activation patterns that were almost identical to those reported by According to RTT, extreme sports are supposed to be appetitive stimuli for subjects with low emotional reactivity and high activity scores. Thus, we expected a positive correlation between activity scale and activations of structures in the reward system: nucleus accumbens, amygdala and orbitofrontal cortex. On the other hand, we predicted the same category of stimuli to be aversive for high emotionally reactive subjects. This prediction was based on the findings indicating that in subjects watching aversive stimuli neuroticism is associated with increased activation in brain regions involved in general emotion processing, including the middle cingulate gyrus and dorsal  prefrontal cortex . As emotThe obtained results did not provide support for the hypotheses involving activity trait. The only positive correlation in high arousing sports condition was observed in medial orbitofrontal gyrus. Interestingly, negative correlation with the BOLD signal in the same brain area was observed for perseverance and emotional reactivity. This result is particularly interesting because of the postulated role of the orbitofrontal cortex. In the context of the present study based on video stimuli, it is important to underline the connection between orbitofrontal cortex (OFC) with the thalamus and visual cortex. Researchers showed that OFC plays an important role in positive evaluation of visual stimuli . At the Other results for high arousing movies showed a negative correlation between BOLD signal and endurance in the hippocampus, insular cortex, and lingual gyrus. This result is coherent with the theoretical characteristics of all these traits. RTT defines endurance as the ability to react adequately in situations demanding long-lasting or highly stimulating activity . The evaEmotional reactivity trait scores correlated positively with the BOLD signal in the majority of the limbic system structures  when participants were shown videos depicting sports activities with low stimulative value. These results fully align with predictions of major temperamental theories. Emotional reactivity scale correlates highly and positively with neuroticism as it is defined by both PEN  and Big It is important to underline that some of the presented conclusions require corroboration in further research, due to the limitations of our study. Most importantly, our findings are based on data obtained in the female-only sample. As explained previously, our decision not to include male participants was motivated by the need to maximize the variance of key temperamental characteristics while controlling for the potential confounding effects of sex. At the same time, this approach allowed as to use raw scores obtained from FCB-TI in all correlational analysis, without relying on test norms.p-values in all correlational analyses. We are fully aware of the fact that it is possible that some of the reported significant results might be false-positives, however, given limited power and coherent pattern of key results , we find this approach justified.The second important limitation of our approach stems from the moderate size of our study sample. Additionally, both estimates of fMRI activations and questionnaire measurements offer limited reliability, which negatively affects theoretical upper limits of correlations between activity scores and temperamental traits. These premises motivated our decision to report uncorrected The experimental procedure employed in our study allows to investigate the brain correlates of highly ecologically valid video-stimuli eliciting varying levels of arousal. Firstly, following our expectations, we showed that brain activation patterns were systematically related to the stimulatory value of the presented material, with more pronounced reactions evoked by videos depicting extreme-sports activities. Secondly, correlational analysis revealed an interesting pattern of relationships between temperamental traits and BOLD signal levels. Our results showed that orbitofrontal cortex responds differently to high arousing movie stimuli depending on temperament of the subject. Additionally, we identified a link between high emotional reactivity and activation of the limbic structures providing first ever validation of RTT theory based on fMRI data.It is also worth noting that our results bear some important methodological implications and indicate that controlling for temperamental differences is crucial in research aiming at identification of brain correlates of emotional processes. Whereas most of the published studies focus on controlling the affective aspects of the stimuli, our research shows that individual differences and stimulative properties might play a significant moderating role and determine the evaluative interpretations construed by the subjects. For example, for individuals with high activity scores, extreme sports are appetitive, whereas for reactive subjects the same material might induce anxiety. As suggested by the title of this article, manipulation of perceived risk and stress levels and using close-to-real-life video stimuli might offer a new (and exciting!) avenue for researchers interested in the study of individual differences and brain underpinnings of emotional reactions.This study was carried out in accordance with the recommendations of a local research ethics committee at the SWPS University of Social Sciences and Humanities with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the ethics committee at the SWPS University of Social Sciences and Humanities.MarB, MakB, JS, and MK made substantial contributions to the conception or design of the study. MarB, PS, and AK acquired the data. MarB and MakB analyzed the data. MarB, MakB, and MK interpreted the data. MarB drafted the manuscript. MakB, PS, AK, JS, and MK critically revised the manuscript for important intellectual content. All authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.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.


Gastric cancer patients represent a rather divergent patient group and in certain carefully selected cases of early forms of gastric cancer the D2 gastrectomy could be considered a more radical procedure than the biological and oncological characteristics of the primary tumor on the gastric wall would require. As any unnecessary dissection increases morbidity without always respective survival benefits, an approach that could accurately predict and actually dictate the exact extent of lymph node dissection would be ideal. It is more than logical the assumption that the standard D2 lymphadenectomy could represent an overtreatment in distinct patients groups such as patients with early gastric cancer with favorable pathological characteristics and clinically negative nodes not suitable for endoscopic treatment because this early stage disease shows limited lymph node metastasis incidence and excellent overall survival. Considering that the D2 gastrectomy has a negative impact on the quality of life of gastric cancer patients due to the post-gastrectomy functional results, a concept of a more targeted lymph node dissection, when appropriate, is certainly appealing. It is yet to be proven whether sentinel lymph node navigation surgery can fulfill such expectations providing the appropriate balance between morbidity and oncological safety in selected gastric cancer patients. Gastric cancer is a rather common malignancy, the 6th most common according to the GLOBOCAN 2012 data, with a reported mortality of 8.9/100,000 population . HoweverAs the D2 gastrectomy is a procedure involving major dissections, a quite high associated morbidity and mortality should be anticipated even when performed in highly specialized centers . AdaptinGastric cancer patients represent a rather divergent patient group and in certain cases such as patients with early gastric cancer with favorable pathological characteristics and clinically negative nodes the D2 gastrectomy could be considered a more radical procedure than the biological and oncological characteristics of the primary tumor on the gastric would optimally require. In support of the above, the Japanese Gastric Cancer Association guidelines currently advice a more limited either a D1 or a D1+ lymphadenectomy in these favorable early forms of gastric cancer . ConsideThe sentinel node concept is based on the main principle that the status of the sentinel node i.e., whether it is infiltrated by metastasized malignant cells or not can predict and finally reflect the status of the remaining nodes as well. Under this prism, a negative for metastasis sentinel node could indicate that no other lymph node is infiltrated by malignant cells. Taking this concept one step further, a properly standardized sentinel lymph node navigation surgery could ideally create the conditions for a precise and consequently limited lymph node dissection probably required in selected patient group. On top of all, as the penetration of laparoscopic surgery in gastric cancer treatment armamentarium has recently increased, the surgical community's interest on the topic has been triggered. In the present review, we aimed to provide comprehensive and updated answers to simple questions regarding the technical aspects, the validity of the technique itself as well as the certain indications of the sentinel lymph node navigation concept in gastric cancer surgery.Traditionally, the importance of the lymph node status in gastric cancer was widely acknowledged and appreciated especially by Eastern Asian surgeons. In line with this concept, back in 1973 the Japanese Research Society for the study of gastric cancer aimed to define the lymphatic drainage pattern of the stomach and subsequently standardize lymph node dissections   has become especially popular, an approach aiming to seize and employ the benefits of each tracer at the same time. Indeed, the anticipated increase in the detection rate accuracy by the use of a double tracer has been confirmed by several literature reports and the combined technique has achieved global acceptance among experts , 22. HowTwo different methods have been tested for the administration of the tracer around the primary tumor. The first method includes the injection of the tracer into the sub-mucosal layer of the gastric wall around the primary tumor under endoscopic examination while a sub-serosal injection during the surgical procedure represents the second option. The dye  is injected into the sub-mucosa or the sub-serosa and is distributed evenly around the primary tumor while 2.0 ml of Technetium–99 m colloid solution is injected  in a similar manner using endoscopy .In general, studies failed to demonstrate a significant difference between the sub-mucosal and the sub-serosal injection method in regards to the sentinel lymph node identification rates . HoweverIn general, labeled lymph nodes by the used tracer either dye or radioisotope or both are collected for further examination. Two distinct methods for this procedure have been described and analyzed in the literature. The picked-up method implies the removal of the labeled nodes only. This is currently the technique used to assess the sentinel lymph node status in breast cancer and melanoma. The other method is the, so called in the literature, lymphatic basin dissection . The gasConsequently, lymphatic basin dissection is a selective type of lymphadenectomy which includes the en bloc dissection of the basins where all stained with dye lymph nodes are collected and sent out for pathological analysis intra-operatively , 30. TheProbably the most controversial and troublesome issue in the logistics of the sentinel node concept in gastric cancer surgery is the establishment of an accurate intra-operative diagnosis of lymph node metastasis in a timely manner. Usually, the intraoperative diagnosis of a lymph node metastasis is established by examining the frozen section of the stained node by the classic hematoxylin—eosin staining . A notabIn an attempt to properly address this issue, molecular techniques have been utilized such as the reverse transcriptase—polymerase chain reaction (RT-PCR) or the one-step nucleic acid amplification assay , 36. AriSimilarly, a recent study showed that the use of RT-PCR with the carcino-embryonic antigen as mRNA shows superior sensitivity rates compared with immune-histochemistry for identifying micro-metastasis in the retrieved lymph nodes , 37. TheAlthough sentinel node navigation surgery in gastric cancer has several well-documented advantages, there are indeed limitations and drawbacks in the technique as well. Thus, proper patient selection is of paramount importance in order to highlight the benefits of the technique and not violate the basic oncological principles. Literature reports raise the eligibility to as high as 50% (range 3–50%) of gastric cancer patients , 40–43. The advantages of laparoscopic surgery over conventional surgery such as less postoperative pain, decreased length of hospital stay, superior cosmetic results, and earlier recovery are now widely accepted. In gastric cancer surgery however, questions were raised regarding the oncological efficiency of the procedure as initial reports documented a lower lymph node retrieval rate during the laparoscopic assisted gastrectomy , 50. TheOptimally, the combination of laparoscopic surgery with sentinel node navigation in gastric cancer could further augment the advantages of each procedure with additional benefits for the patients . In geneDespite the recent obvious development on all aspects of sentinel node navigation surgery, there is still a notable controversy in the literature regarding the indications, the safety and the efficiency of the procedure oncologically-wise in gastric cancer. In general, numerous studies have already demonstrated pretty satisfactory results reporting a sentinel node detection rate of 90 to 100% and a metastasis detection sensitivity of up to 100% (Range: 85–100%) , 53–55.There are two important prospective multicenter trials that aimed to test the sentinel node theory in early gastric cancer patients. The Japan Society of Sentinel Node Navigation Surgery study group conducted a multicenter prospective trial analyzing the validity of sentinel node navigation surgery utilizing a dual-tracer (radioactive colloid and isosulfan blue) . Three-hIn 2011, a meta-analysis of the existing feasibility studies was conducted aiming to examine the overall sensitivity of the sentinel node biopsy in gastric cancer patients . The autAnother meta-analysis published a year later by Wang et al. yielded quite different results i.e., sentinel node detection rate, sensitivity, negative predictive value and accuracy of 93.7, 76.9, 90.3, and 92.0%, respectively. The authors reported a significantly better sensitivity and detection rates when the dual tracer technique is used, when the tracer is injected in the sub-mucosa and when the picked up nodes are examined via immuno-histochemical staining . In geneAs quality of patients' life is increasingly becoming the crucial factor in evaluating the available treatment options, an approach of less invasive surgical procedures would be more often adapted in the future. In this direction, provided that sentinel node navigation surgery would achieve the desired accuracy levels, treatment individualization in the form of deviations from the established lymphadenectomy, currently the D2, could find their role in the gastric cancer surgical armamentarium. Certainly, the need for studies in the field of high level of evidence is obvious. The SENORITA trial, which compares the laparoscopic sentinel node biopsy or stomach preserving surgery  with the laparoscopy assisted gastrectomy with lymph node dissection (D1+ or more) (control arm) is ongoing and the first results are awaited by the end of 2020 . Another, phase III trial is in progress as well . The accumulation of the results of these clinical trials could indeed throw some additional light on the field and further clarify the role of the sentinel node navigation surgery in the gastric cancer treatment armamentarium.However, there is still lot of things to be standardized in regards to the technique itself that would allow its widespread use. One of the most important is the part of the intra-operative pathology. The standard tactic today is to divide the frozen lymph node specimen into parts which are then in turn examined by using hematoxylin/eosin staining. The JCOG0302 trial revealed the inadequacy of the one plane frozen section examination to determine accurately the metastatic status of the retrieved node. Thus, multiple slice frozen section examination is mandatory in order to achieve high diagnostic accuracy . HoweverA rapid and simple to use approach is the one-step nucleic acid amplification assay. This is an automated system that uses the reverse-transcription loop-mediated isothermal amplification method for gene amplification and might have the answers to the above mentioned limitations . ResultsIn conclusion, sentinel node navigation surgery, validated appropriately, can probably play a significant, but well-defined, role in the definite treatment of gastric cancer creating, when appropriate, the conditions for targeted but oncologically effective lymphadenectomies. However, there are several problems on the technique itself and on the indications as well that require convincing answers such as easy to use and to visualize tracers in real operative time, brief and precise pathology and ultimately appropriate patient selection. In regards to tracers, combining tracers (dye plus isotope) seems to be the most effective and commonly followed approach due to the increased detection rates. Hematoxylin/eosin staining is still the mostly utilized method in regards to staining of the picked up nodes due to its overall advantages compared to the other more precise but the hard to use in everyday practice methods. The approach of lymphatic basin dissection seems promising because under certain circumstances could address and counterbalance existing limitations of the procedure in its current form. The lessons learned from the terminated study due to the unacceptable results, if appreciated appropriately, can turn from insurmountable obstacles to the stepping stone for actual progress on the field with direct clinical correspondence.DS and KT made substantial contributions to the acquisition, the analysis, and the interpretation of the literature data. DS drafted the paper. DS and KT revised the paper critically for important intellectual content. Both authors gave their final approval of the final submitted 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.


Mindfulness Based Health Care (MBHC) provides meditation techniques that may help to mitigate negative impact of dementia caregiving. We conducted a pilot randomized controlled trial with two parallel groups including 42 caregivers of Alzheimer patients (21 pairs). MBHC group learned the practice of mindfulness meditation once a week through 8 classes; control group did not receive any therapy. Anxiety and depression symptoms were the primary outcomes assessed in two occasions, i.e. at baseline and the end of the program, using the Hospital Anxiety and Depression scale respectively. Neuropsychiatric disorders of Alzheimer patients were also measured with Neuropsychiatric Inventory-Questionnaire. The details of the randomized controlled trial were described in clinicaltrial.gov NCT03858283. In this abstract, we presented the results of a pilot study conducted with 42 caregivers. Robust linear regression using MM-type estimator was performed to evaluate the changes in neuropsychiatric disorders in patients and anxiety and depression symptoms in caregivers adjusting for Score of Scale Global Deterioration. We observed that, compared to the control group, the MBHC group showed a tendency to a reduction in the total score Neuropsychiatric Inventor  and the depression symptoms in the caregivers . However, no changes were observed in the anxiety symptoms of the caregivers. In conclusion, the results of this pilot study suggested a positive effective on the reduction of neuropsychiatric symptoms in patents as well as on the depression in the caregivers. Nevertheless, these findings should be confirmed in a further complete study.


Road traffic injuries (RTIs) stands as one of the leading causes of mortality and morbidity across the globe. Effective injury surveillance systems and pre-hospital and in-hospital interventions set up in developing countries have shown promising results in controlling the problem. This study aimed to standardise and evaluate an evidence-based intervention for safety, efficacy and quality of post-crash pre-hospital and in-hospital trauma care services to improve the outcome in RTI victims. In addition, it establishes the android-based trauma registry for effective RTI surveillance.This multi-centric, prospective, observational study is commissioned by the Indian Council of Medical Research (ICMR) as a National Task Force Project. This study is being conducted in five sites, viz., Anand, Bengaluru, Delhi, Lucknow and Thrissur located across India. Each centre will have a level I, two level II and three level III trauma hospitals. The study will be carried out in four phases namely: i) preparatory phase, ii) trauma registry establishment and pre-intervention data collection, iii) intervention and iv) impact evaluation. The preparatory phase, which lasts for four months includes the situational analysis pertaining to managing RTIs. Trauma registry will be initiated from the fifth month. Pre-intervention data will be collected for six months. The intervention will be conducted for six months in the form of prehospital notification, training for trauma care providers and trauma care quality improvement. Post-intervention data collection will continue for 12 months and the impact of the intervention will be assessed. The primary outcome measure will be early preventable mortality, defined as death at 24 hours after admission for patients with a calculated probability of survival >50% based on their injury severity score. Road traffic injuries (RTIs) stands as one of the leading causes of mortality and morbidity across the globe. Approximately 1.24 million people die every year on the roads across the world, and another 20 to 50 million sustain non-fatal injuries as a result of RTIs. Eighty per cent of road traffic deaths occur in middle-income countries, which account for 72% of the world’s population but only with 52% of the world’s registered vehicles  to study the prehospital trauma care system and emergency medical services (EMS) available in the district for identifying important components, which can improve the trauma health system in the district, (ii) to establish a prehospital care intervention through training of first responders and bystanders and sensitizing them about the importance of pre-hospital notification, (iii) to establish the intervention for emergency care by reorienting trauma care personnel and improving the facilities, (iv) to assess the overall impact of prehospital and in-hospital trauma care on the outcome of the RTI victims and (v) to establish a trauma registry system on electronic platform enabling data capturing through Android phones.This would be a multi-centric, prospective, observational, cohort study. The ICMR selected five Level I trauma centres  from diAdministrative support: Administrative support will be sought from the District Collector, the Superintendent of Police, the District Medical Officer, the Mayor and other functionaries in the city/district. The elected representatives of the city and district will be met to seek their support. A document highlighting the burden of RTIs will be prepared for each site and the same will be used for advocacy efforts.Identification and defining the role of partner hospitals : The partner hospitals would be identified on the basis of their geographical location and selected purposively at each of the five sites. Each level I hospital will select two level II and three level III hospitals. Once identified the roles and responsibilities of partner hospitals and the nodal officers at each hospital will be defined and given as written protocol.Situation analysis: The situation of the district in terms of the epidemiology of RTIs and trauma care facilities available in the district would be done. The trauma care capacity will be assessed in all the 30 hospitals. Other facilities like EMS and ambulance services available will be listed in the documents. A situational analysis tool based on the WHO’s publication - “Guidelines for Essential Trauma Care” would be used for this purpose , various types of data coding, injury severity scoring and training on other data management tools would also be undertaken for research personnel. This is aimed not only to help in the current project but also to help in capacity building for future trauma registries.Data collection: Registry data collection will be done by research personnel under the supervision of the principal investigator and other senior staff based on the preset registry proforma. The proforma used for trauma registry is appended to this paper as The intervention phase will last for 6 months and shall include: (a) education of the first responders, (b) prehospital notification training, (c) acute trauma care training and improving the quality of care.(a) Education of the first responders: The intervention in this study is to educate and train the first-responders like ambulance or emergency medical technician personnel, police and fire and safety services staff. The training will include basic education on the initial assessment of a trauma patient in the form of AIIMS Trauma First Responder (TFR) course. The training will be for 6–8 hours for one day conducted once every month for 6 months during the intervention period.(b) Prehospital notification training: The recipient hospital needs to be notified about patient’s basic injuries and vitals while en-route, so that the receiving hospital has enough time to assemble a team, which is ready to receive and treat the patient upon arrival.Level I trauma hospital will be issued mobile phones, with a dedicated toll-free number as part of the intervention. Panels comprising representatives of trauma hospital and feeding pre-hospital providers would be convened and, locally-tailored protocols and forms for the following made: (i) notification that specifies about whom, to whom and when the notification should be given, and what information should be communicated; (ii) responding at the receiving end, in particular assembling a receiving trauma team for cases requiring immediate resuscitation; (iii) documentation of call details, including the time of call, the information provided, and perceptions of its utility and any care that ensued; and (iv) structured handover upon arrival to the hospital.(c) Acute trauma care training and improving the quality of care: AIIMS Trauma Assessment and Management (ATAM) course will be conducted providing training to the doctors and nurses catering to the RTI victims. ATAM would be held once every month at the level I hospital for a total duration of 6 months during the intervention phase. ATAM is a two-day course, which provides structured training in acute trauma management with special emphasis on skills training. Pre and post-test will be conducted with each course as a part of a quality improvement (QI) programme.QI activities will be implemented according to the WHO guidelines to become focal points for training in their region. The intervention will include the WHO trauma QI training course for key clinicians and administrators, conducted during the first six months, followed by mentoring of development of the necessary structures and processes to conduct regular mortality and morbidity (M & M) meetings, preventable death reviews, audit filters, risk-adjusted benchmarking of key performance indicators where relevant and loop closure. The trainers and mentors will be drawn from the project leadership team.Post-intervention trauma registry data collection would be carried out for 12 months after the intervention phase. Internal and external quality assurance would be carried out on a monthly basis. As mentioned at every stage of the study, the impact of the intervention will be measured through various outcome indicators, including the patients’ outcome like death, length of stay in hospital, morbidity, disability, etc. The necessary data for an impact evaluation will be obtained through the registry. Both pre- and post-intervention comparisons among various outcome variables will be made.The primary outcome measure will be early preventable mortality, defined as death at 24 hours after admission for patients with a calculated probability of survival >50% based on their injury severity score. Secondary outcomes will be (i) the proportion of patients for whom the notification was indicated who had notification initiated, (ii) the proportion of patients who met criteria for assembly of a receiving trauma team for whom a team was assembled and (iii) ICU and hospital length of stay, etc.Quantitative data (continuous variables) will be presented as mean, standard deviation and range  or as median and interquartile range . Ordinal and nominal data shall be presented as proportion and percentage. Student’s t-test will be used to compare the difference of means whereas; the Wilcoxon ranked sum test will be used to evaluate the statistical significance of the difference of medians. The Chi-square test or Fisher’s exact test shall be used to compare the difference of proportions . A p value of <0.05 was considered as the minimum level for statistical significance.There will be internal and external quality monitoring at various levels. As an internal quality, a data entry specifies limits of variable value to avoid the entry-level errors. Hardcopy of the forms will be sent to the apex body on a weekly basis. Independent entry of the same forms will be carried out at apex centre, Delhi. The data manager will randomly select 10% the forms and cross-check with the data entry.The study protocols were approved by the institutional ethics committees (IECs) of the respective level I hospitals/institutes. Each of the five IECs approved the study for the corresponding centre.The findings of the study will be shared with the pre-hospital and in-hospital personnel of the participating centres. The study findings will be disseminated through conducting workshops and publishing policy briefs. Dissemination workshops and policy briefs will primarily target policymakers, health administrators and other government functionaries of both state and national governments. Further, this research team will involve in advocacy campaigns to bring and implement trauma care guidelines in the country. The results will be presented at national and international scientific meetings and will be published in indexed scientific journals.It is expected that this national task project shall study the existing pre-hospital and in-hospital services in geographically diverse districts from different regions of India, foster collaboration amongst researchers from different leading trauma centres of the country, facilitate capacity building in various districts and assess the effectiveness of interventional measures like pre-hospital notification and training of pre-hospital workers and in-hospital medical and paramedical personnel, etc. This study will provide comprehensive epidemiology and outcome of RTIs. Currently, in India, the EMS are fragmented and a few states have recently implemented a version of EMS that responds to a toll-free call for the medical emergencies . The finThis intervention research on safety, efficacy and quality of post-crash pre-hospital and in-hospital trauma care services to improve the outcome in RTI victims is timely. Majority of the RTI deaths is due to unreachability for basic and integrated emergency services, which lead to failure in utilizing golden hour. The intervention on prehospital care includes education and training for prehospital care and prehospital notification, standardized hospital selection, a mandatory checklist for persons attending RTI and prior notification of arrival. Pre-hospital notification alone has been found to be associated with reduced mortality and improved outcome . Faster This study further aimed to educate and train the first-responders on components of prehospital notification including basic life support. The intervention will be made to ensure the availability of ambulances to transport the critically injured patients according to prior set criteria. Strengthening the quality of care within the study hospitals is another component intervention. It is evident that an organized trauma system leads to improvement in patient outcome . This kiThe strengths of the study include implementation of trauma care intervention with trauma registry in electronic format across geographically diverse regions – some hospitals are completely urban whereas others are rural. The study also aimed to evaluate the effects of identical pre-hospital and in-hospital training among a large population of pre-hospital and in-hospital personnel. The analysis will have some limitations. We are not certain about the generalization of results. The selection of trauma care facilities is not random, rather they were selected purposively. However, these facilities have been selected from five different geographical zones to represent the country. Also, there is the limited external validity due to inclusion of level I trauma centre which is likely to receive complicated and severely injured patients and might show higher mortality rate, whereas the level II and III trauma centres might refer complicated and severely injured patients to higher centres and consequently a lower mortality rate might be observed in level II and level III hospitals. Also, we need to consider mitigating factors like introduction of government schemes for RTI patients (wherein even patients with minor injuries are likely to attend level-1 trauma centre) and re-configuration of medical and administrative responsibilities at trauma centres . There are a lot of confounders in large multi-centric studies and reduction in mortality might not be dependent solely on the intervention components. Despite these limitations, the study followed rigorous methodology by adopting both national and international trauma care guidelines.Evidence of improvement of RTI victims through quality post-crash pre-hospital and in-hospital trauma care will emerge from this study. This study will further help to capture real-time data of road traffic injury patients attending the various hospitals. If the trauma training program for pre-hospital workers and in-hospital medical and paramedical workers is successful in improving the knowledge and various skill sets, then it could be implemented in different regions of India. The results of this study will contribute to the setting of research priorities and formulate trauma care guidelines and policies.


Orbital trauma is a commonly encountered entity in clinical practice, especially in cases of head trauma. Although fractures of the orbit are rare, they can present in an emergency setting owing to associated complications such as orbital encephaloceles. We present a case of a paediatric male patient who presented with post-traumatic proptosis and diminution of vision and was diagnosed with orbital encephalocele. The child's vision recovered completely and proptosis of the eye decreased, compared with the time of presentation. Despite persistent counselling, the patient and his parents did not give consent for surgical correction and he was discharged as leaving against medical advice. Post-traumatic orbital encephaloceles are caused as a result of blunt cranial trauma. Early treatment and diagnosis is extremely important in the optimum management and good long-term prognosis of the patient. The most common symptoms include proptosis and visual disturbances. Early diagnosis of orbital encepaloceles is extremely important and cross-sectional imaging plays an important role. We present a case of a 12-year-old male child who developed unilateral post-traumatic orbital encephalocele.Post-traumatic fractures of the roof of the orbit are rare.A 12-year-old male presented to the neurosurgery department of our hospital in a semiconscious condition with complaints of vomiting, proptosis, blackening of upper eyelid and significant diminution of vision of the right eye with an evolution of 6 h. The patient reported falling from a height (trauma) 6 h earlier. The patient had a Glasgow Coma Scale score of 10/15 (E2M5V3). The patient also had swelling of the scalp over the right frontal region. There was no history of nasal bleed or loss of consciousness. On clinical examination, periorbital oedema was noted. A provisional diagnosis of orbital haematoma was made in accordance with the history of the patient and a non-contrast-enhanced CT scan of the head and orbit was advised.Based on the patient's history and clinical examination, our first diagnosis was retro-orbital haematoma along with intracranial haemorrhage. Orbital injury was also suspected and a B-scan was planned.The CT scans revealed a fracture of the roof of the right orbit with posterosuperior displacement of the bone fragment. A hypodense, heterogeneous lesion was seen extending from the anterior cranial fossa into the right orbit, causing anterior protrusion of the eyeball that resulted in proptosis  and 2. IThe periorbital oedema and blackening of the eyelid were managed conservatively. The patient’s vision recovered completely since the eye swelling and proptosis decreased, although proptosis was not completely reduced. The vomiting stopped and the patient’s Glasgow Coma Scale score became normal.The patient recovered from most of his symptoms, except proptosis. The problem was to the patient and his parents and surgical correction was advised for which they were referred to a high complexity healthcare.1 Proptosis, eye swelling, visual disturbances, subconjunctival haemorrhage and restricted movement of the eye are the most common presenting symptoms, with compression leading to optic nerve atrophy being the main long-term complication.6 Oedema of the retro-ocular tissues results in congestion of the veins, which pushes the eyeball forward. This leads to stretching of the extraocular muscles and the nerves, which further compresses the draining veins.7 Beyond a certain limit, the retinal artery gets occluded, resulting in permanent visual loss.Although orbital encephaloceles are more common in the younger population, their occurrence in adults has also been reported.3 Growing fractures of the orbit are associated with orbital trauma.5Isolated fractures of the orbit are classified as blow-in or blow-out fractures according to the displacement of the fractured bony fragment. If the fractured fragment lies within the orbit, it is classified as a blow-in fracture, and if the fractured fragment lies outside the orbit in the periorbital space, it is classified as a blow-out fracture. A blow-in fracture results in increased intraorbital pressure and/or impingement syndromes, which sometimes leads to irreversible neurological damage, whereas a blow-out fracture causes disruption of the orbital wall , resulting in entrapment syndromes of the periorbital structures.5 Materials used in reconstruction of the orbital roof include titanium mesh and screws with a mixture of bone powder and fibrin glue, and temporalis fascia as grafts. The former supposedly has better cosmetic results.8 Surgeries are sometimes delayed by 7–10 days until the swelling subsides.9Post-traumatic cases requiring urgent orbital surgery include: progressive loss of vision, progressive proptosis and radiologically demonstrated bony spicule pressing on the optic nerve. Visual disturbances along with increased intraorbital pressure are the two most common causes of emergency surgery in cases of orbital trauma.10 CT scan has proven to be an extremely reliable investigation in cases of orbital trauma, more so with fractures of the roof of the orbit, as was in our case.10Previous case reports have focused on the clinical and management aspects of orbital encephalocele. Not much emphasis has been placed on imaging findings of the entity. Imaging is frequently required in orbital trauma as clinical evaluation is usually limited by soft tissue swelling. Plain film radiographs do not provide adequate information regarding the extent of injury, hence CT scan is the investigation of choice.The diagnosis of orbital encephalocele would surely have been missed without optimum imaging investigation, and we here would like to emphasize the importance of cross-sectional imaging in cases of orbital trauma.Although imaging with CT is highly recommended and is the imaging of choice in cases of trauma, MRI is the imaging investigation of choice for orbital encephalocele.Written informed consent was taken from the patient's parents.


The objective of the current study was to investigate the effect of four different crank fore-aft positions on elbow flexion and shoulder protraction, the consequent propulsion kinetics and the physiological responses during handcycling.Twelve able-bodied male participants volunteered in this study. Crank fore-aft positions were standardised at 94%, 97%, 100% and 103% of the participants’ arm length. Two submaximal 3 min trials were performed at a fixed cadence (70 rpm), in a recumbent handcyle attached to an ergometer at two fixed power outputs (30W and 60W). Elbow flexion, shoulder protraction, propulsion kinetics and physiological responses of the participants were continuously measured.As crank fore-aft distance increased, a decrease in elbow flexion  and an increase shoulder protraction was observed . The percentage of work done in the pull phase increased as well , which was in line with an increased peak torque during the pull phase  and reduced peak torque during the push phase . Despite these changes in work distribution, there were no significant changes in gross mechanical efficiency . The same patterns were observed in the 30W condition.From a biomechanical perspective the crank position closest to the trunk (94%) seems to be advantageous, because it evens the load over the push and pull phase, which reduces speed fluctuations, without causing an increase in whole body energy expenditure and hence a decrease of gross mechanical efficiency. These findings may help handcyclists to optimize their recumbent handcycle configuration. Recumbent handcycles are used for recreational sports and have been further optimized for two Paralympic sports, i.e. handcycling and paratriathlon . These tWhen exploring the effects of handcycling configuration, both the biomechanical and the physiological effects are relevant with regard to performance . The proPrevious studies have looked at the effect of changing the crank fore-aft position in a number of different experimental setups, with a great diversity in the number of participants, types of handcycles used and subsequent recommendations. Two studies used able-bodied participants and an arm crank ergometer; the first with an asynchronous crank setup (thus dissimilar to handcycling) found an increase in oxygen uptake during a maximal test to exhaustion at the crank position closest to the participant  . The secInterpretation of the aforementioned findings for athletic recumbent handcycling is further made difficult because a standardised definition of crank fore-aft positions is currently lacking. Although handcycling can be considered a closed chain activity, there are still multiple degrees of freedom, especially in the combination of elbow flexion/extension with the amount of shoulder protraction. Hence, both might be influenced when changing the crank fore-aft position and therefore should both be considered . Yet, prSubsequently the objective of the current study was to investigate the effect of four different crank fore-aft positions on 1) the resulting elbow flexion/extension and shoulder protraction angles, 2) the consequent propulsion kinetics (torque profile around the crank-axis), and 3) the physiological responses . Based on the previous work on efficiency in arm crank ergometry and other handcycles, a closer crank fore-aft position is hypothesized to be more efficient ,19.Twelve able-bodied male participants with little or no previous experience of handcycling volunteered for this study . All participants provided written informed consent after receiving written and verbal information about the protocol and objectives of the study. The study was performed in accordance with the declaration of Helsinki and approved by the local university ethics committee .Trials were conducted in a custom made, fully adjustable handcycle . Fifty-five reflective markers were placed on the participants: nine were placed on the thorax ; twelve were placed on each upper arm , four on each forearm , four on each hand , and a cluster of three markers was placed bilaterally on the acromion . The lasRaw kinematic data was first analysed using the Vicon Nexus software package (version 2.5), and was further analysed using custom written Matlab scripts . Euler angles for all segments were calculated following the International Society of Biomechanics recommendations . The elbCycle kinetics were measured with an instrumented crank  which measured the effective torques exerted around the crank-axis, combined with the angle of the crank. Different kinetic parameters were calculated as descriptors for force distribution over the cycle: minimal torque at the end of the push- and pull phase, maximal torque in the push and pull phase, and percentage of work done in the pull phase . The pus2) and carbon dioxide (CO2) were continuously measured with a breath-by-breath gas analyser , that also included a heart rate monitor for synchronized heartrate measurements . Before each session the gas analyser was calibrated according to the manufacturer’s recommendations. Data collected over the last minute of each exercise trial were averaged and taken to reflect physiological steady-state handcycling. From the VO2 (L/min), and respiratory exchange ratio (RER) the energy expenditure (EE) was determined  over energy expenditure:All statistical analyses were done using the Statistical Package for Social Sciences . Two-way repeated measures analyses of variance (ANOVA) were performed to explore differences in kinematics, kinetics and physiological parameters between crank fore-aft positions (94–103%) and power output (30/60W). Significance level was set at p < 0.05. Mauchly’s test of sphericity was performed prior to conducting the ANOVA to test if the assumption of sphericity was met. When a significant effect was found, post hoc contrasts were performed to determine where the differences occurred (with Bonferroni correction). For the minimal torque at the end of the push phase a difference contrast was used, where the mean of each configuration was compared to the mean of the previous configuration. For the percentage of work done a simple contrast was used where the mean of each configuration was compared to the 94% configuration.All participants were able to complete the protocol while maintaining a steady cadence of 70 rpm in each condition. Only the kinematic data of participant 5 in the 100% condition was not recorded properly.The measured arm length, crank position difference between the closest and furthest configurations (manipulation range), and average elbow extension and shoulder protraction angles in each configuration are shown for each participant in The kinetic variables are shown in 2, ME and HR are shown in 2, ME and HR were not significantly affected by the configurations. On the other hand the higher power output of the 60W condition did lead to a higher VO2, GME and HR compared to the 30W condition.Test results for VOThis is the first study to examine the biomechanical and physiological effects of different crank fore-aft positions during recumbent handcycling of able-bodied participants relative to arm length. The increase in crank fore-aft position resulted in a decrease in elbow flexion and an increase in shoulder protraction. Consequently, the distribution of work shifted towards an increase of work being performed in the pull phase and a decrease of work being performed in the push phase over the propulsion cycle. This shift was concomitant with an increased peak torque during the pull phase and a reduced peak torque during the push phase. Despite these clear changes in work distribution between the push and pull phase, there were no significant changes in physiological responses at the same power output, as hypothesised based on previous literature.A novel approach to standardize crank fore-aft position was implemented to define changes in crank fore-aft position relative to the participants’ arm length. This allowed for an abundant number of combinations of shoulder protraction and elbow flexion to help rotate the crank of the handcycle. Indeed, from the results it becomes clear that both elbow flexion and shoulder protraction are used to accommodate the different experimental crank fore-aft positions. For the whole group both a decrease in elbow flexion and an increase of shoulder protraction was present for each increase in crank fore-aft position. Moreover, at an individual level, the chosen combination of angles differed considerably between participants. Participants found different solutions and/or have different preferences with regard to the task, which might also be dependent on upper-body physical fitness and motor learning of this relatively new task . This emNext to the increased elbow flexion and decreased shoulder protraction in the closer crank fore-aft positions, the participants also increased the work done in the push phase. Since participants were performing at a fixed cadence and power output this meant they consequently reduced the work done in the pull phase to maintain a constant power output. Such a more equal distribution of work is generally preferred in handcycle races , as thisYet, the changes in crank fore-aft position will also have influenced the movement pattern and muscle mechanics in terms of length-force and force-velocity characteristics around the elbow and shoulder joint ,11,29,302, ME or HR. This was similar to the results of Arnet et al. 2014, who also couldn’t identify the best crank fore-aft position based on physiological measurements [Although a closer crank fore-aft position led to a different kinetic profile, no such effects were found for the physiological variables of VOurements . Their sThe results of the 60W condition showed RER values slightly above one, indicating an anaerobic component to the participants’ work, indicative of a non-steady-state workload. Previous work with able-bodied participants were also confronted with this problem, but at much higher workloads ,19,22,35Based on the results of the current study different recommendations to athletic handcyclists in a recumbent handcycle can be made, in light of several possible limitations. We showed the effect of crank fore-aft position in a group of relatively untrained able-bodied individuals in a static lab-setup without steering or forward-backward oscillations, highlighting the changes in work distribution. Athletic handcyclists on the other hand have different impairments and have to manoeuvre themselves outside during a race . The limDespite these differences we still expect the following to be of relevance. First, the crank fore-aft position does not only influence elbow flexion, but also shoulder protraction. Therefore the possibility to produce work by shoulder pro/re traction is also expected to be present in athletic handcyclists and needs to be investigated further ,37. SecoTo optimize athletic handcycle performance there is a need to better understand what the ideal work distribution over the propulsion cycle is with regard to multiple outcomes, such as optimal power production, injury risk and local fatigue of muscles. Currently, multiple instrumented crank systems are available with a high sample rate of the exerted torque. The systematic use of such devices during competition, training and carefully controlled lab experiments have the potential to further our understanding about optimal cyclic upper body exercise and creating an optimal interface between the athlete and the handcycle. Moreover, we encourage the relatively little population of high performance handcyclists to share data about their handcycle setup and current choice of crank fore-aft position, to further the sport as a whole and help with the general understanding about optimal fit and performance, which will help the professionalisation of the sport in the future.The current study revealed that an increase in crank fore-aft position resulted in a decreased elbow flexion and increased shoulder protraction during recumbent handcycling which led to an increase of work being performed in the pull phase and a decrease of work being performed in the push phase, without changing gross mechanical efficiency. In line with our hypothesis, the closest position possible for the athlete resulted in a more even distribution of work, because it evens the load over the pull and push phase and reduces forward speed fluctuations. Contrary to our expectations no changes in whole body energy expenditure were found. These findings in able-bodied participants helps build theory on optimal handcycle configuration, to be applied and tested in in actual elite handcyclists with a broad range of impairments.S1 File(SAV)Click here for additional data file.


The tremendously unbalanced distribution of species richness across clades in the tree of life is often interpreted as the result of variation in the rates of diversification, which may themselves respond to trait evolution. Even though this is likely a widespread pattern, not all diverse groups of organisms exhibit heterogeneity in their dynamics of diversification. Testing and characterizing the processes driving the evolution of clades with steady rates of diversification over long periods of time are of importance in order to have a full understanding of the build-up of biodiversity through time.We studied the macroevolutionary history of the species-rich tree fern family Cyatheaceae and inferred a time-calibrated phylogeny of the family including extinct and extant species using the recently developed fossilized birth–death method. We tested whether the high diversity of Cyatheaceae is the result of episodes of rapid diversification associated with phenotypic and ecological differentiation or driven by stable but low rates of diversification. We compared the rates of diversification across clades, modelled the evolution of body size and climatic preferences and tested for trait-dependent diversification.This ancient group diversified at a low and constant rate during its long evolutionary history. Morphological and climatic niche evolution were found to be overall highly conserved, although we detected several shifts in the rates of evolution of climatic preferences, linked to changes in elevation. The diversification of the family occurred gradually, within limited phenotypic and ecological boundaries, and yet resulted in a remarkable species richness.Our study indicates that Cyatheaceae is a diverse clade which slowly accumulated morphological, ecological and taxonomic diversity over a long evolutionary period and provides a compelling example of the tropics as a museum of biodiversity. The distribution of biodiversity is strikingly unbalanced when comparing species richness among lineages and one of the main challenges in evolutionary biology is to understand the underlying factors that are responsible for this uneven distribution . This chThe heterogeneity of species richness across clades is likely the result of variations in the rates of speciation or extinction . ChangesAngraecum orchids  exhibited a constant rate of diversification during most of its long evolutionary history, but several increases in the rate of diversification have punctuated the recent evolution of this group . SimilarIn this context, the long-term drivers of the diversification history of old and species-rich plant clades can give important insights into the build-up of biodiversity through time. We focused here on the scaly tree fern family Cyatheaceae, an iconic plant group of humid forests comprising about 660 known species distributed worldwide in tropical and subtropical regions. This species richness is remarkable compared with the seven other families of the Cyatheales, which contain from a single species in the Thyrsopteridaceae to ~35 species in the Dicksoniaceae . PhylogeHere, we combined molecular data at an unprecedented level of taxonomic sampling with fossil information to reconstruct a new dated phylogenetic tree of the Cyatheaceae. The origin of the group dates back to the Jurassic and recent theory suggests that diversification in such an old group could be the result of a steady but slow accumulation of species through time  was collected and identified personally (by one of the authors); voucher material for published sequences  of the sister family Dicksoniaceae.Our dataset includes 323 species of Cyatheaceae representing ~49 % of the total extant diversity of the group. All genera were included, with sampling fractions of 49 % in equences  was alsolsophila . As outg® Plant II  kit following the manufacturer’s protocol. We generated sequence data for three chloroplast markers: trnL-trnF [including the trnL group I intron (g1i) and the trnL-trnF intergenic spacer (IGS)], trnG-trnR  and the most recent common ancestor of all extant species is 140 Myr old (95 % HPD of crown node. 108.63–170.86). Sphaeropteris had a crown age of ~125 Myr and the remaining three genera had crown ages between 75 and 80 Myr. Overall, the node-dating analysis resulted in a similar topology with constantly younger age estimates, especially in the deeper nodes of the tree  than for Gymnosphaera and Sphaeropteris , neither speciation nor extinction rates were actually significantly different in the two groups  lineages per Myr at the root and 0.070 (95 % HPD 0.055–0.078) lineages per Myr at the tips] and BAMM detected no shift in the rate of diversification across the Cyatheaceae . In Bayeo groups . Per-clao groups . DespiteCyathea  similar to the spores of extant Cyathea are found in Siberia. Records of Cyatheaceae are also known from Antarctica in the Eocene, but are restricted to Central America by the Pliocene  for conducting field work and sequencing, and from SYNTHESYS (GB-TAF-4927 and GB-TAF-6305) for herbarium studies. N.S. and M.K. received funding from the Swiss National Science Foundation (CRSII3-147630) and N.S. from the University of Lausanne.


Preparation and formulation of amorphous solid dispersions (ASDs) are becoming more and more popular in the pharmaceutical field because the dissolution of poorly water-soluble drugs can be effectively improved this way, which can lead to increased bioavailability in many cases. During downstream processing of ASDs, technologists need to keep in mind both traditional challenges and the newest trends. In the last decade, the pharmaceutical industry began to display considerable interest in continuous processing, which can be explained with their potential advantages such as smaller footprint, easier scale-up, and more consistent product, better quality and quality assurance. Continuous downstream processing of drug-loaded ASDs opens new ways for automatic operation. Therefore, the formulation of poorly water-soluble drugs may be more effective and safe. However, developments can be challenging due to the poor flowability and feeding properties of ASDs. Consequently, this review pays special attention to these characteristics since the feeding of the components greatly influences the content uniformity in the final dosage form. The main purpose of this paper is to summarize the most important steps of the possible ASD-based continuous downstream processes in order to give a clear overview of current course lines and future perspectives. With the increasing number of poorly water-soluble drug candidates , the impTM and SymdekoTM are especially interesting in the context of this review, since one of the APIs (Ivacaftor) in Vertex’s combination drug products possesses relatively weak dissolution properties and bioavailability in crystalline form; therefore, preparation of an ASD form by spray drying was applied to eliminate the above-mentioned disadvantages . R. R123]. co-glycolic acid) concentration. The authors also reveal the importance of process parameters such as voltage, feeding rate, and the polymer concentration, which are key factors in the formulation of particles.A conclusion similar to the previous examples can be stated in the case of materials prepared by the electrospraying method . During In the case of fibers prepared with electrospinning, grinding is indispensable to handle the electrospun material in the further formulation steps. Development of grindable fibers improved the flowability of protein-type drug-loaded electrospun samples and thus it facilitates the tableting process . However® for in situ coatings with glidant , can be promising surface modification methods to improve the flow properties of ASDs, too [® or FEM) because these techniques are easily insertable into continuous manufacturing processes. In addition, these systems are suitable not only by spray-dried products but in the case of other solvent-method prepared ASDs. For instance, electrospinning could be an alternative to freeze-drying while the continuous collection of fibers also seems to be feasible using a cyclone [The presented examples point out that designing of reliable feeding with ASDs to a continuous formulation line could be extremely challenging due to the poor flowability and low bulk density of the powders . For this reason, it is worth to take an outlook for ASDs in context with feeding and surface modification as well. It is important to note that ASD samples with smaller particle size  have quite similar flow properties to the micronized APIs in general thus the handling and the downstream processing need the same considerations as by APIs with poor flowability . ConsequSDs, too ,132. In SDs, too . The res cyclone . However cyclone . On the In addition, surface modification is also applicable for decreasing the electrostatic charging of the powders to avoid the charge generation during the formulation processes. Jallo et al., investigated magnetically assisted impaction coating as a potential method to improve the flow and decrease the electrostatic charging of micronized acetaminophen . During Taking together, these methods would seem to suggest that increasing the flowability of bulk powders could be accomplished without using the well-known granulation, too. Nevertheless, a feeding step should always be inserted before the granulation during continuous manufacturing lines and thus, particle engineering and surface modification are especially significant by designing continuous formulation lines of ASDs.Another side of the feeding efficiency is feeder characteristics that can be modified to enable faster feed rates and more reliable weight variation. Different evolving, shape, and size of the feeders offer a variety of applicability to weigh continuously the diverse pharmaceutical blends. For instance, Coperion K-Tron, Brabender Technologie, or Técnicas de Alimentación Dinámica (TAD) fabricate manifold pharmaceutical and other feeders for handling most bulk materials in a wide range of applications ,137,138.Most commonly used pharmaceutical feeders operate on the principle of loss-in-weight (LIW) and mostly consist of one or two screws . WeighinVariations of the LIW systems differ in the type of the moving element, which can be a screw, rotating cell, belt, or vibratory channel. The latter three were not too widespread in the pharmaceutical field so far for dosing APIs, excipients or blends. For instance, a vibratory feeder was rather applied for measuring powder flow by using a small amount of the materials . HoweverPolymer-based ASDs can be quite sticky or fluffy materials, which is why the selection of a good feeder may mean a solution to handle the bad powder characteristics of these samples. Engisch and Muzzio published several papers in connection with loss-in-weight feeders. One of their work introduces the characterization of a K-Tron KT35 loss-in-weight feeder with different screws by using three distinct powders . Both voBesides the material flow properties, the feed rate deviations caused by hopper refill are also fairly important in a practical application point of view . During The next step in this area is the control of the feeder, which was successfully accomplished by Joshua Hanson . During Increased interest in continuous technologies and a growing number of ASD-loaded drug products raise the issue of the joint examination of the two areas. ASDs enable the development of poorly water-soluble drug candidates into final dosage forms while the dissolution of the API improves and thus, greater bioavailability could be achieved in many cases. Downstream processing of these materials is getting more attention not only in the academic area but also in the industry. However, published articles relating to the continuous formulation of ASDs confirm that it is quite a new aspect in the pharmaceutical field. The majority of the research groups attempt to find alternative ways instead of the conventional formulation process of tablets such as combination HME with IM or 3D printing. Although these solutions avoid the barriers caused by the poor flowability of ASDs, the scalability is limited in most cases. In contrast, the traditional formulation line is more suitable for mass production thus improving the flow properties is a hot topic at present. As it was presented in this review, flowability can be enhanced by various methods and feeder marketed companies offer more and more expedient equipment as well. Considering all this, continuous downstream processing of ASD is worth investigating closer in the future to get more reliable processes and products.


Circadian rhythms produce a biological measure of the time of day. In plants, circadian regulation forms an essential adaptation to the fluctuating environment. Most of our knowledge of the molecular aspects of circadian regulation in plants is derived from laboratory experiments that are performed under controlled conditions. However, it is emerging that the circadian clock has complex roles in the coordination of the transcriptome under natural conditions, in both naturally occurring populations of plants and in crop species. In this review, we consider recent insights into circadian regulation under natural conditions. We examine how circadian regulation is integrated with the acute responses of plants to the daily and seasonally fluctuating environment that also presents environmental stresses, in order to coordinate the transcriptome and dynamically adapt plants to their continuously changing environment. The Earth rotates on its axis approximately every 24 h. This causes daily cycles in a variety of environmental conditions, such as the presence, spectrum and direction of light, ambient temperature, relative humidity, and the activity of herbivores. Furthermore, the axial tilt of the Earth causes seasonal changes in the photoperiod and other environmental parameters. The daily environmental cycles appear to have driven the evolution of circadian rhythms. Circadian rhythms are biological cycles that have a period of about 24 h and persist in the absence of external cues. A key feature of circadian rhythms is that they define the daily phase of biological processes, and therefore organize the daily timing of the transcriptome so that cellular processes occur at appropriate times of day and in a coordinated manner . CircadiThe molecular functioning of plant circadian rhythms and the circadian organization of the transcriptome has been investigated predominantly under laboratory conditions. However, circadian rhythms are thought to have evolved as an adaptation to naturally fluctuating environments, and an understanding of their importance for ecosystems and field-grown crops requires knowledge of circadian regulation under natural conditions. Here, we explore the recent expansion of understanding of molecular and cellular aspects of circadian regulation under natural conditions, with a focus on the regulation of the transcriptome.Arabidopsis thaliana, and the reader is referred to other review articles for greater depth  and LATE ELONGATED HYPOCOTYL (LHY) are MYB-like transcription factors forming part of a core feedback loop within the circadian oscillator (CCA1 and LHY transcript abundance peaks in the morning and decreases throughout the day. CCA1 and LHY repress the expression of the evening-phased TIMING OF CAB EXPRESSION1 (TOC1) by binding to its promoter (CCA1 and LHY (GIGANTEA (GI), LUXa ARRHYTHMO (LUX), BROTHER OF LUX ARRHYTHMO (BOA), EARLY FLOWERING3 (ELF3), and ELF4 , which is within the same protein family as CCA1 and LHY  promoter motifs to induce their transcription  proteins are major regulators of cold acclimation . CBF1, 2ive dawn . The cirs of day . CCA1 anolerance . Interest manner . There ibundance . This isbundance . Furtherbundance . This suCBF gene expression that are concurrent with temperature decreases during the night  within the plant . This is the process whereby more than one transcript can be generated from a single precursor mRNA (pre-mRNA) through the use of alternative splice sites in response to developmental cues, environmental cues, and stresses . These abidopsis . AS occubidopsis , with mun period .Arabidopsis transcriptome highlights a massive and rapid differential AS in response to cold temperature exposure, including a substantial proportion of circadian clock associated genes  have provided insights into roles for circadian regulation under naturally fluctuating conditions, with a focus upon ecology and ecophysiology. For example, antisense-mediated misexpression of NaLHY and NaTOC1 identified potential roles for the circadian oscillator gating photosynthetic responses to light under field conditions , The Leverhulme Trust (RPG-2018-216), Consejo Nacional de Ciencia y Tecnología Mexico (Conacyt), the University of Bristol, and the Bristol Centre for Agricultural Innovation for funding.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.