The chasse step is one of the most important footwork maneuvers used in table tennis. The purpose of this study was to investigate the lower limb kinematic differences of table tennis athletes of different genders when using the chasse step. The 3D VICON motion analysis system was used to capture related kinematics data. The main finding of this study was that the step times for male athletes (MA) were shorter in the backward phase (BP) and significantly longer in the forward phase (FP) than for female athletes (FA) during the chasse step. Compared with FA, knee external rotation for MA was larger during the BP. MA showed a smaller knee flexion range of motion (ROM) in the BP and larger knee extension ROM in the FP. Moreover, hip flexion and adduction for MA were significantly greater than for FA. In the FP, the internal rotational velocity of the hip joint was significantly greater. MA showed larger hip internal rotation ROM in the FP but smaller hip external rotation ROM in the BP. The differences between genders can help coaches personalize their training programs and improve the performance of both male and female table tennis athletes. With increasing global development and interest, table tennis has become popularized all over the world . The posThe lower limb biomechanics of footwork during table tennis performance has attracted much research. Table tennis players usually use three basic footwork patterns, including one-step, side-step, and cross-step, to move into a suitable position to play a forehand topspin shot. Side-step and cross-step movements show higher peak pressure, knee flexion angles, and knee moment than one-step . AccordiProviding opportunities for the development of all elements of table tennis, including footwork, is a crucial part of training and competition. The basic principle of training is individual training , the purThere are also differences in male and female table tennis athletes. Gender differences exist in the morphological structure of table tennis players . ZagattoPrevious studies have described the kinematics of the forehand and backhand upper limbs of table tennis players of different genders. To our knowledge, the kinematics of the lower limbs using a chasse step has not been studied in detail. Therefore, the purpose of this study was to evaluate the differences between genders in the lower limb joint angles, range of motion (ROM), and joint velocity in three planes. Motion time was also processed for further analysis to investigate differences between males and females in table tennis. We hypothesized that male and female table tennis athletes differ in the angle parameters and movement patterns of their lower limb joints during the chasse step. This study may provide practical guidance for table tennis coaches for chasse step training. The findings may also assist in establishing individual training programs for table tennis players to improve and enhance athletic performance. Additionally, the results may also help develop footwork training systems that may prevent injuries.As outlined in Prior to the formal experiment, the height and weight values for all participants were recorded with a calibrated weighing scale and stadiometer. The kinematic information was collected using an 8-camera Vicon motion analysis system  at a frequency of 200 Hz during the test. Vicon Nexus software was used to synchronously capture kinematics data. A total of thirty-six reflective markers (diameter: 14 mm) were used (these included anterior and posterior (left and right) superior iliac spine; medial and lateral (left and right) condyle; medial and lateral (left and right) malleolus; first and fifth (left and right) metatarsal heads, distal interphalangeal joint (left and right) of the second toe, as well as a total of six tracking clusters attached to the middle and lateral (left and right) thigh, shank, and heel ,20. PrevAs outlined in All participants were informed of the experimental requirements and procedures. Before data collection, all participants had time to become familiar with the experimental environment. They were required to warm up for 20 min and to perform a multiball training regime for 10 min that incorporated the chasse step. Participants hit the ball  using a forehand topspin during the warm-up and test. During the test, all the participants wore the same table tennis match shoes and used the same table tennis racket. Participants were asked to hit balls with their maximum effort onto the target zone , just as they would in a formal match. Each participant successfully completed at least ten performances and the kinematics of each test were recorded synchronously.As outlined in The chasse step refers to two specific movements, namely the backward phase (BP) and forward phase (FP) of the dominant foot in a footwork movement. The data for the lower limb joint angles, range of motion (ROM), joint velocity, and motion time in the sagittal, frontal, and transverse planes during the entire motion cycle for each participant were recorded for further processing and analysis. Data were analyzed using SPSS  and the statistical significance level was set to 0.05. The Shapiro–Wilk test was used to verify the normal distribution of variables. Independent t-tests were performed to determine the kinematic differences between the chasse step movements of male and female table tennis players for each variable of interest. The analysis included joint angle, motion time, joint velocity, and range of motion (ROM) measurements of the ankle, knee, and hip joints. MATLAB scripts were written to extract joint angle, ROM, and joint velocity values and enabled calculation of the differences.Data were exported to MATLAB R2017A  and processed using scripts written for specific data sets. The open-source SPM 1D script  was used for statistical analysis. The chasse step SPM 1D analysis was performed using a custom MATLAB script  and a seAs shown in In the sagittal plane, MA showed significantly less knee flexion in the BP as compared to FA but significantly greater knee extension in the FP during the whole procedure of the chasse step. The hip flexion for MA was significantly lower than that for FA over the entire motion cycle. In the frontal plane, knee abduction for MA was significantly lower in the BP than for FA. The hip joint adduction and abduction for MA were significantly greater than for FA in the BP and FP, respectively. In addition, FA had significantly greater internal and external rotation than MA in the transverse plane in the BP and FP. However, the knee joints of MA showed greater external rotation than for FA during the BP.The ROM values for MA and FA in all planes during BP and FP are shown in The objective of this research was to analyze gender differences based on the lower limb kinematics of the table tennis chasse step. The key findings of this study were as follows. In terms of time spent, there was a significant difference between MA and FA for the entire motion cycle. Moreover, there were significant differences between male and female table tennis athletes in the backward phase (BP) and forward phase (FP). Hip flexion for MA was significantly lower than for FA, while hip adduction and abduction were significantly greater during the entire motion cycle. The knee abduction for MA was significantly lower than for FA in the BP and MA showed greater external rotation than FA. Compared to FA, MA showed less knee flexion in the BP but greater knee extension in the FP. The hip flexion ROM for MA was significantly greater than for FA throughout the entire motion cycle. MA showed significantly greater hip abduction (ROM) than FA in the BP. Compared with FA, MA showed less hip external rotation (ROM) during the BP and greater hip internal rotation (ROM) during the FP. For MA, the internal rotational velocity of the hip joint was significantly greater in the FP.In terms of time, MA had quicker times in the BP but longer times in the FP than FA during the chasse step. The entire motion cycle took about one second for both MA and FA, which indicates that male table tennis athletes have a longer forward phase. This could demonstrate that male athletes could be prepared for short periods of intense activity during the chasse step. This is consistent with previous research. Table tennis players have limited time to hit the ball, so it is beneficial for them to improve their swing speed in a short time . Table tDuring the BP stage, MA exhibited greater inversion and internal rotation of the ankle and greater joint velocity during inversion of the ankle compared to FA. Moreover, knee flexion was significantly lower in the BP but extension was significantly greater in the FP than for FA. The external and internal rotation for MA in the BP and FP were both greater than for FA. MA have a greater range of joint movement. This may mean that MA are better prepared for the lower limb than FA during BP. High-level athletes can effectively use the knee joint to rotate the upper limbs, which can result in more body movements than low-level athletes . Muscle A further finding was that hip flexion and adduction were significantly greater for MA than for FA. MA showed larger hip internal rotation ROM in the FP but smaller hip external rotation ROM in the BP. Moreover, the internal rotational velocity of the hip joint was significantly greater in the FP. In racket sports, one of the most critical factors is the rotation of the trunk axis . The speThe results of this study could be useful for table tennis coaches and athletes. The variation of movement parameters between individuals reflects that the sports skills of male and female table tennis athletes are very individualized. Therefore, coaches should pay attention to gender differences between table tennis players when creating or adopting techniques and tactics for athletes during chasse step training. For table tennis players, individualized training programs require consideration to prevent sports injuries and improve sports performance. The coordination of the movement patterns of the chasse step can also be considered as important practical outcomes of this study.There are several limitations that need consideration in this study. Firstly, we only looked at male and female table tennis players at the same level. It would also be useful to study table tennis players of different training levels and different ages. Secondly, this study only compared the biomechanical differences of the dominant lower extremity. Non-dominant limbs may also contribute significantly to athletic performance. Thirdly, only the kinematics data for the chasse step and the kinetics data were collected. In future studies, different subject populations should be considered, investigating the relationships between the upper and lower limbs and the combined biomechanical characteristics in combination with use of the racket.In this study, we systematically analyzed the lower limb kinematics of advanced table tennis athletes of different genders using the chasse step. We outlined the lower limb joint movements of advanced table tennis athletes of different genders and the use of the chasse step. The findings from this study suggest that coaches and athletes when practicing the chasse step should pay attention to the role of the knee joint. Attention should be focused on strengthening the knee and core to reduce the risk of injury during the chasse step. The differences observed between genders in this study can provide a reference for coaches to personalize and customize programs during training, resulting in improved competition performance in table tennis athletes. It can also give guidance and suggestions for the training of male and female athletes in other sports.


Despite marked advances in therapeutics, HIV infection remains a leading cause of morbidity and mortality worldwide. HIV infection is associated with cardiovascular complications including myocardial dysfunction. The description of HIV-associated cardiomyopathy (HIVAC) has evolved over time from a predominantly dilated cardiomyopathy with systolic dysfunction to one of subclinical diastolic dysfunction. Multimodality cardiovascular imaging plays an integral role in our understanding of the etiology and pathogenesis of HIVAC. Such imaging is also essential in the evaluation of individuals with chronic HIV disease who present with cardiac symptoms, especially of heart failure. In the present review, we will highlight current evidence for the role of multimodality imaging in establishing the diagnosis, etiology and pathophysiology of HIVAC as well as guiding treatment and assessing prognosis. Human immunodeficiency virus (HIV) infection remains a leading cause of morbidity and mortality worldwide . Of the HIV infection is associated with various cardiovascular manifestations. In settings where ART is readily accessible, PWH are living longer but continue to have chronic low-grade inflammation despite immunosuppression . In addiThe presentation of myocardial disease in PWH ranges from incidental asymptomatic findings on autopsy or cardiovascular imaging to symptomatic heart failure. Decades after its recognition, the etiology and pathophysiology of HIV-associated cardiomyopathy (HIVAC) remains a topic of intense speculation with no consensus criteria for its definition. Nevertheless, its description has evolved from the pre-HAART era, when HIVAC was characterized by a dilated cardiomyopathy with systolic dysfunction associated with end-stage HIV disease and a poor prognosis. Morbidity and mortality occurred largely in the context of myocarditis, opportunistic infections, toxicity from medications, nutritional disorders, autoimmune mechanisms and inflammation. In more recent times, subclinical diastolic dysfunction has become the hallmark of HIVAC in individuals with treated HIV infection .Cardiac imaging plays an integral role in the assessment of PWH who present with cardiac symptoms and signs especially those of heart failure. In the current review, we will highlight evidence for the role of multimodality imaging in establishing the diagnosis, etiology, and pathophysiology of HIVAC as well as guiding treatment and assessing prognosis.The epidemiology of HIVAC has changed over the course of time from its initial description characterized by left ventricular (LV) systolic dysfunction to its current description of varying levels of diastolic dysfunction. Data on the prevalence of HIVAC is largely from studies conducted in the United States and Europe despite the fact that more than two-thirds of PWH are found in Sub-Saharan Africa . With thThe pathogenesis of HIVAC is unclear but is likely multifactorial. Prior to the widespread implementation of ART, systolic dysfunction was thought to be mainly due to direct viral invasion of the myocardium, with or without myocarditis by the HIV virus or secondary to opportunistic infections such as toxoplasmosis and cryptococcosis . HoweverEchocardiography remains the first line imaging modality in assessing myocardial function. It is readily available, cost effective and robust in detecting both systolic and diastolic dysfunction. Prior to HAART, HIVAC was recognized on transthoracic echocardiography (TTE) as systolic LV dysfunction with varying degrees of LV dilatation. However, with the onset of HAART, HIVAC is largely recognized on TTE as subclinical diastolic dysfunction.3 in these patients. The HIV-HEART study assessed the prevalence of abnormalities in cardiac structure and function in 803 PWH in the era of ART  had a dilated cardiomyopathy, 33 (22%) had LV dysfunction and 9 (6%) had isolated right ventricular (RV) dysfunction . These ra of ART . The autEchocardiography has been shown to be instrumental in early detection of cardiovascular disease and has also been helpful for researchers to diagnose differences between heart disease in PWH and in people without HIV. One study analyzed 1,195 participants from the Multicenter AIDS Cohort (MACS) study who underwent TTE exams demonstrating that men with HIV had a larger LV mass index and right ventricular size compared to controls . In addiOther studies evaluated LV systolic function by tissue Doppler strain echocardiography in PWH and participants without HIV. One study demonstrated that while LVEF in PWH was slightly lower than in patients who were uninfected, the LVEF values were still within normal limits. However, PWH had subtle cardiac dysfunction, as evidenced by reduced LV strain . SubclinRight ventricular (RV) dysfunction is relatively common in PWH occurring largely in the setting of dilated cardiomyopathy or with varying degrees of HIV associated pulmonary hypertension (PH) . IsolateThe evidence highlights the value of echocardiography in the evaluation of myocardial function in PWH. Studies from the pre-HAART era demonstrate the pivotal role that echocardiography played in diagnosing systolic dysfunction in symptomatic patients often with advanced HIV disease. The same remains true today, and echocardiography remains an essential first line modality for assessing cardiac structure and function in PWH who present with heart failure symptoms. This non-invasive approach is important in characterizing biventricular function and cardiac structure as well as excluding other non-myocardial causes of symptoms. In the case of LV systolic dysfunction, evidence-based goal directed medical therapy should be considered per guideline recommendations . AlthougCardiac magnetic resonance (CMR) has been used to detect subtle and subclinical myocardial abnormalities, contributing to the current understanding of the pathogenesis of HIVAC. Untreated HIV infection is characterized by an immunodeficient state. In contrast, patients with well-treated HIV infection are in a state of immune activation. Several studies have shown a correlation between elevated inflammatory biomarkers and cardiovascular events in PWH . This obCMR is a useful tool in assessing the role of inflammation and fibrosis in myocardial dysfunction in PWH. CMR can detect several components of inflammation, which include edema and fibrosis depending on the extent of cardiac involvement and stage of disease. p < 0.001)  . A more < 0.001) . CMR has< 0.001) . HoweverCMR plays an important role in the evaluation of HIV associated myocarditis. Before the introduction of ART, an early autopsy study demonstrated myocarditis in 52% of patients who died of AIDS . HoweverMeasures of tissue characterization using CMR also have prognostic value for PWH. In a recent study, CMR was used to quantify ECV, reflective of myocardial inflammation or fibrosis, and showed that PWH have significantly higher ECV fraction when compared to people without HIV. The higher ECV value corresponded to more diffuse fibrosis, and studies have also shown a link between higher ECV values and increased adverse cardiovascular events. A prospective observational study evaluated the prognostic association between CMR measures and cardiovascular outcomes including heart failure in PWH on HAART. It was found that patients with diffuse myocardial fibrosis on CMR had a higher rate of cardiovascular events .Lastly, novel non-contrast CMR techniques have been developed that may help in the work up of PWH who are prone to developing early vascular disease and microvascular dysfunction that may contribute to the pathogenesis of cardiomyopathy . ImpaireCardiac computed tomography (CT) and coronary CT Angiography (CCTA) have emerged as important imaging tools for evaluating both clinical and subclinical CAD in PWH. An analysis of the MACS cohort, a large cohort of HIV infected and matched uninfected men showed that after adjusting for known CVD risk factors, HIV infected men had an increased prevalence of non-calcified and mixed plaques compared to HIV uninfected men using CCTA . CCTA waCoronary artery calcification (CAC) is a highly specific marker of coronary atherosclerosis and is frequently employed to screen for CAD and assess risk for cardiovascular events . The MACPWH may present with symptomatic heart failure secondary to ischemic heart disease. In this setting CCTA is useful in the diagnostic workup of CAD. The utility of CT to establish the diagnosis of CAD as well as its value as a gatekeeper for invasive coronary angiography in patients with heart failure and LV systolic dysfunction was shown in a study of 93 patients with newly diagnosed heart failure of unknown etiology . If the Nuclear medicine-based techniques have the ability to identify vascular inflammation and can permit the early detection of vascular disease in PWH . The degA summary of multimodality cardiovascular imaging techniques used for HIV-related heart disease is shown in The introduction of HAART has led to a paradigm shift in the presentation of cardiovascular disease in PWH including that of HIVAC. Although the etiopathogenesis of HIVAC remains unclear, multimodality imaging has played a role in defining various putative mechanisms including inflammation and myocardial fibrosis. Multimodality imaging is also crucial in establishing a diagnosis of HIVAC in symptomatic patients. Although many studies have established prognosis in HIV patients with cardiomyopathy and systolic dysfunction, the prognostic significance as well as progression of diastolic dysfunction in HIVAC remains largely unknown and further long-term studies are needed. In addition, the mechanism and significance of right ventricular dysfunction especially in the absence of PH and LV dysfunction should be explored further. In summary, an approach tailored to the clinical presentation of the patient should be used to guide the use of cardiovascular imaging to identify myocardial dysfunction, investigate the possible underlying causes and facilitate appropriate preventive and evidence-based treatment for this condition.EG, RR, and AH drafted the manuscript. MM, GS, EG, SB, SS, and BC reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.EG and AH received support from the Women as One Foundation. Further support was received from the National Institute of Health (R01HL147660) and the Johns Hopkins Center for AIDS Research (P30AI094189), Ruth L. Kirschstein Institutional National Research Service Award; T32HL007227-Pathophysiology of Myocardial Disease, the National Institute of Health.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The guidelines on antithrombotic treatment in patients with symptomatic peripheral artery disease (PAD) undergoing peripheral revascularization of the lower extremities were developed based on heterogeneous trials, assessing various dose regimens and recruiting patients who were subjected to different revascularization procedures.  To compare efficacy and safety of treatments used in patients with PAD undergoing peripheral revascularization accounting for between-trial heterogeneity and large dispersion of the quality of evidence.  A systematic literature review of randomised controlled trials (RCTs) recruiting adult patients with PAD receiving antithrombotics was conducted until January 2020. Hazard ratios (HR) were pooled using Bayesian network meta-analysis. The estimated between-treatment effects were presented as HR together with 95% credible intervals. The base case analysis included studies recruiting patients following recent peripheral revascularization, who received treatment regimens administered within the recommended therapeutic window, while a sensitivity scenario included all identified trials.  Thirteen RCTs were identified . Five trials, recruiting an overall of 8349 patients, were considered for the base case analysis. Of those, 6564 patients were recruited in the VOYAGER PAD trial comparing rivaroxaban plus aspirin (RIV plus ASA) versus ASA. RIV plus ASA was associated with a lower risk of repeated peripheral revascularization versus ASA monotherapy , however having a trend towards an increased rate of major bleeding . There was no evidence for differences between RIV plus ASA and dual antiplatelet therapy and vitamin K antagonists plus ASA. Similar results were observed in sensitivity analyses.  RIV plus ASA is associated with reduced risk of revascularization compared with ASA monotherapy, but the evidence for other comparators, in particular antiplatelet regimens, was insufficient to guide treatment decisions and highlights the challenge in establishing the magnitude of comparative efficacy using existing RCTs. Peripheral artery disease (PAD) is a common cardiovascular (CV) system disease with the global prevalence exceeding 200 million people and incidence of about 11 million in 2017 –6. CLI lThe clinical trials on the antithrombotic medication differ noticeably in terms of quality and sample size, with limited evidence for the efficacy and safety of antiplatelet medication used in patients who have undergone revascularization, in particular for those after recent endovascular procedures . Due to A systematic literature review (SLR) was conducted to identify randomised controlled trials (RCTs) on adult patients with acute symptomatic PAD, presenting the clinical evidence for the following therapeutic options: RIV plus ASA, CLO plus ASA, ASA monotherapy, CLO monotherapy, vitamin K antagonists (VKAs) with or without ASA or CLO, and a placebo. The search was conducted in January 2020 in MEDLINE, MEDLINE In-Process, EMBASE, and CENTRAL. No timeframe and geographical scope restrictions were imposed; however, for conferences/congresses searches, only records issued from 2015 on were considered. Inclusion criteria are summarised in The selection of RCTs was conducted by 2 analysts working independently, and any disagreements between the 2 analysts were resolved by a third analyst. Data from studies meeting all inclusion criteria were extracted by one analyst; its quality was thoroughly checked by the second analyst. The risk of bias was assessed for each study using the tool developed by the Cochrane Collaboration .The intention of this analysis was to compare the RIV plus ASA regimen with treatments recommended by the current clinical practice guidelines to treat patients with PAD after revascularization. We considered all RCTs assessing antiplatelet therapies or anticoagulant treatment enrolling patients with PAD of lower extremity with and without a history of recent revascularization to increase the power of this NMA –6. BasedTreatments were compared regarding clinically relevant outcomes reported across analysed studies . EfficacTwo trials assessing RIV plus ASA in patients with PAD were identified through the SLR , 16. BotAn NMA in Bayesian framework was used to compare RIV plus ASA versus other treatments . The NMAThe model inputs are natural logarithms of hazard ratio (log(HR)) for between-treatment comparison and the corresponding SE(log(HR)). When respective trials reported estimates calculated after several interim analyses, only final estimates corresponding to the longest available follow-up were included for the NMA. Neither of the included trials reported information suggesting violation of proportionality of hazards. For studies not reporting HRs, they were estimated by fitting the exponential survival curve to the reported number of events.Three chains were initiated with noninformative priors and run in parallel for each analysis. The convergence between chains was checked using the Brooks-Gelman-Rubin diagnostic and trace plots. There were no closed loops in the evidence networks; thus, there was no reason for the analysis of consistency.The NMA was conducted using fixed- and random-effect models with deviance information criterion (DIC) as the indicator of model fit to clinical data. The fixed-effect model was preferred; however, the random-effect model was considered relevant when associated with DIC value lower by ≥5 points . The resOverall, 14 RCTs were identified, including a small, phase II study (RIVAL PAD ), which Input data for the NMA is presented in Supplementary Tables The risk of bias was evaluated for all included trials and summarised in Supplementary Table Eleven out of 13 clinical trials enrolled just patients with lower extremity PAD; however, the protocols of 2 RCTs  allowedAs mentioned before, the included trials differed regarding a history of the previous revascularization, type of procedures, etc. Eight out of the 13 RCTs were designed to assess therapeutic effects following recent peripheral revascularization. They recruited patients who recently underwent revascularization using either surgical  Base Case. The aim of this analysis was to assess between-treatment differences in efficacy and safety based on RCTs with a high level of homogeneity regarding the target population and assessing treatment regimens administered in accordance with clinical practice guidelines [idelines . TherefoThere was limited number of studies meeting the inclusion criteria for the base case analysis; thus, the comparison with some of the predefined comparators including VKA monotherapy, CLO monotherapy, and the combination treatment including CLO plus ASA was not feasible.(2) Sensitivity Analysis. The aim of this analysis was to allow for the comparison versus comparators not assessed in the base case and analyse the robustness of the comparative results based on relaxed inclusion/exclusion criteria while acknowledging the heterogeneity introduced with that. This analysis was conducted based on the 13 studies included in the NMA.Fixed-effect models were considered for each comparison based on DIC criterion and considering that in most cases only one study was available for each comparison; therefore, the heterogeneity parameter could not be estimated. A consistency analysis was not conducted as all the networks had star-like shape without closed loops allowing to compare between direct and indirect evidence.The trials eligible for the base case analysis allowed to form a network of evidence linking RIV plus ASA (VOYAGER PAD) with CLO plus ASA  and VKA plus ASA (Johnson 2002&2004) through ASA monotherapy. RIV plus ASA and CLO plus ASA could formally be compared regarding all outcomes of interest except for ALI, which was assessed only in the VOYAGER PAD trial . On the Consistent with the results of the VOYAGER PAD trial , this anAdditional trials included in the sensitivity analysis allowed for the assessment of relative treatment effects also versus CLO monotherapy and VKA monotherapy, although the former option was only the comparison for CV deaths, IS, any stroke, and the risk of MI.Consistent with the base case analysis, RIV plus ASA was associated with a lower risk of peripheral revascularization compared with ASA monotherapy . For the majority of the remaining outcomes, there was no significant difference between RIV plus ASA and ASA except for the risk of major bleeding, which was significantly higher in the RIV plus ASA group  compared to ASA alone.The NMA did not reveal significant treatment differences, with the exception for the comparison with VKA plus ASA regarding major bleeding; there was a lower risk associated with RIV plus ASA .The inclusion of additional studies enrolling stable population leads to a nonsignificant modification of the relative effects. The results of the CHARISMA trial  favouredThere were no other major differences in the direction and significance of the effect estimates between the base case scenario and the sensitivity analysis, which could modify the inference.Input data on amputations for the NMAs are presented in With this NMA, we attempted to summarise existing evidence on efficacy and safety profiles of treatments used in patients with PAD undergoing peripheral revascularization and accounting for the between-trial heterogeneity and large dispersion of the quality of evidence.p = 0.009) with no significant increase of the rate of TIMI major bleeding  and a significant increase in ISTH major bleeding events .The SLR conducted to collect data for the NMA revealed scarcity and serious limitations of available clinical data. We identified only 5 RCTs reporting adequate results that were eligible for the base case analysis and allowed to compare RIV plus ASA only with 2 regimens: CLO plus ASA and VKA plus ASA. Of those, the VOYAGER PAD study was the largest trial enrolling 6564 out of 8449 patients recruited in all studies included for the base case scenario. The study was designed and powered to compare RIV plus ASA versus ASA in a double-blinded fashion regarding clinically relevant outcomes and showed a significant reduction of the primary efficacy endpoint defined as a composite of acute limb ischemia, major amputation for vascular causes, myocardial infarction, ischemic stroke, or death from cardiovascular causes. All participants underwent a recent peripheral revascularization prior to a random allocation to treatment groups, which was stratified according to the type of revascularization procedure (endovascular (including hybrid) vs. surgical) and according to clopidogrel use among those who underwent an endovascular procedure . The priWhile the large VOYAGER study provided high-quality results for assessing the clinical effectiveness of RIV plus ASA, the evidence for other therapeutic options in a postrevascularization setting is limited. ASA and ASA plus CLO were compared in patients after endovascular procedures in only 2 RCTs (Cassar 2005 ) recruitp = 0.02) including intracranial bleed, hospitalization for bleeding, an operation for control of bleeding, or a blood transfusion. Neither of the trials identified through an SLR provided clinical evidence for the efficacy of CLO monotherapy in patients following revascularization; thus, the evidence supporting the use in that population is questionable.One trial (CASPAR ) compareThis NMA suggests that RIV in combination with ASA is associated with reduced risk of peripheral revascularization compared with ASA monotherapy, but there seems to be no differences between RIV plus ASA and other treatment options. However, such an indirect comparison has major limitation due to the high heterogeneity of the included trials. The sensitivity analysis with broader inclusion criteria, but with an even more increased heterogeneity, came to the same result. With one exception, the inclusion of additional trials led to an increased estimate of the risk of major bleeding in the VKA plus ASA group compared with RIV plus ASA. The results of this NMA were still imprecise since not all studies included in the network were of sufficient quality and power to draw reliable conclusions based on indirect treatment comparison. Included trials were not powered for the assessment of the individual clinical outcomes but were designed to assess either composite outcomes or surrogates. The results of the sensitivity analysis were associated with high uncertainty due to associated between-trial heterogeneity. Therefore, although this NMA was conducted in accordance with the highest methodological principles, the available clinical evidence is insufficient to draw reliable conclusions regarding the relative effectiveness and safety of the therapies used in patients after revascularization of peripheral arteries.The main limitations of the identified scientific evidence are the inadequate samples of included trials and the related insufficient statistical power to assess respective clinically relevant outcomes. In addition, this NMA with a star-like evidence network inherited the limitations from the individual pairwise comparisons, which means that the quality of the comparison between RIV plus ASA and comparators is limited by the quality of evidence for comparators. Thus, small trials on comparators, not always designed to assess clinically relevant outcomes, are insufficient to draw reliable conclusions regarding relative efficacy and safety between the treatments used in clinical practice in this target population. The low power of this analysis and the between-trial heterogeneity with high probability explains the lack of significant differences between treatments assessed within this NMA. The definition of major bleeding was heterogeneous across included studies (Supplementary Table In summary, the results of this NMA are considered imprecise due to the low power of some of the included trials to assess relevant clinical outcomes and due to the high between-trial heterogeneity. Therefore, although this NMA was conducted in accordance with high methodological principles, no reliable conclusions regarding efficacy and safety of therapies in symptomatic PAD patients after a recent revascularization can be drawn. To assess clinical efficacy and safety of, for example, clopidogrel or other anticoagulant therapies in such a population, well-powered, randomised double-blind clinical studies like the VOYAGER trial are required.There was limited clinical evidence for the therapies used in the treatment of patients with PAD undergoing peripheral revascularization procedures of the lower extremities. Of these, RIV plus ASA was assessed in the largest clinical program on over 11,500 patients with PAD, of which 6564 were enrolled following recent peripheral revascularization. This analysis suggests that RIV in combination with ASA is associated with reduced risk of revascularization compared with ASA monotherapy, but the evidence for comparators was insufficient to improve treatment decisions and highlights the challenge in establishing the magnitude of comparative treatment effects using existing RCT data. Robust evaluation of clinical outcomes may therefore require extending the scope of the evaluation beyond RCT data.


Exosomes are small nanoscale vesicles with a double-layered lipid membrane structure secreted by cells, and almost all types of cells can secrete exosomes. Exosomes carry a variety of biologically active contents such as nucleic acids and proteins, and play an important role not only in intercellular information exchange and signal transduction, but also in various pathophysiological processes in the human body. Surface-enhanced Raman Spectroscopy (SERS) uses light to interact with nanostructured materials such as gold and silver to produce a strong surface plasmon resonance effect, which can significantly enhance the Raman signal of molecules adsorbed on the surface of nanostructures to obtain a rich fingerprint of the sample itself or Raman probe molecules with ultra-sensitivity. The unique advantages of SERS, such as non-invasive and high sensitivity, good selectivity, fast analysis speed, and low water interference, make it a promising technology for life science and clinical testing applications. In this paper, we briefly introduce exosomes and the current main detection methods. We also describe the basic principles of SERS and the progress of the application of unlabeled and labeled SERS in exosome detection. This paper also summarizes the value of SERS-based exosome assays for early tumor diagnosis. The exosome was originally isolated from sheep reticulocytes as a small vesicle with the characteristics of the reticulocyte cytosol . Researc2/molecule and is susceptible to fluorescence interference  and the exte RNAl SERS label (labeled method) are two independent methods for direct and indirect detection of biomolecules. The labeling method requires an appropriate dye label. If the label has resonance under a certain excitation line, it can provide an additional enhanced signal, so the detection sensitivity of the labeling method is higher. Instead of labeling, all the information obtained is the amino acid skeleton of the protein. The reproducibility of the spectrum is poor, the non-reproducibility of protein adsorption sites and the denaturation of protein adsorption on the metal surface will all be studied for non-labeling methods. Bring difficulties. However, the information given by non-labeled means can analyze protein structure more directly, which is of great help to protein analysis.Nucleic acid is a biological macromolecular compound formed by nucleotide as a synthetic unit. It is the most basic genetic material of life and plays a decisive role in a series of major life phenomena such as growth, inheritance, and evolution of life. Carrying out nucleic acid molecular diagnosis is of great significance to promoting the development of human health and medical treatment. SERS has unique technical advantages in the detection and analysis of biological samples such as nucleic acids. First of all, SERS has low requirements on the shape and size of the sample to be tested, which can save complicated sample pretreatment steps. Secondly, SERS has a small sample requirement and is suitable for the detection of trace and trace samples. In addition, SERS can achieve rapid detection, generally within 30 s to complete the detection of a sample. The introduction of Raman labeling technology can achieve the purpose of strong specific detection. Moreover, because the Raman scattering of water is very weak, the Raman spectroscopy technique is very suitable for the detection of samples in the water environment. SERS can also be combined with other detection methods to increase detection sensitivity and specificity. SERS combined with PCR nucleic acid detection method can successfully realize the recombination and concentration amplification of the target sequence, so as to achieve the purpose of ultra-sensitive detection. The nucleic acid SERS detection based on enzyme digestion technology mainly relies on the excellent SERS enhancement performance of the “hot spots” between metal nanoparticles, uses the self-assembly of ss-DNA to increase the probability of hot spots formation, and uses enzyme digestion reactions to eliminate hot spots to achieve SERS signals. Change from weak to strong and then from strong to weak.However, there is no research report comparing SERS and other traditional detection methods in the detection of exosomal-derived proteins or nucleic acids. Whether SERS has outstanding advantages in the detection of exosomal-derived proteins or nucleic acids still needs further research.Exosomes are promising biomarkers present in body fluids and cell lines in cancers. As described above, plenty of SERS-based exosomes have been proposed in combination with specific recognition/separation/amplification techniques for qualitative/quantitative analysis of individual targets .Ovarian cancer is the most lethal gynecologic malignancy with a 5-years survival rate of only 47.4%, seriously endangering women’s physical and mental health . A silve3O4@tio2 nanoparticles. Exosomal PD-L1 was labeled and quantified by adding anti-PD-L1 antibody-modified Au@Ag@MBA SERS tags. Based on personalized SERS signal analysis, it was possible to differentiate NSCLC patients from healthy controls and the potential efficacy of immunotherapy -positive breast cancer patients. HER2-positive Exosomes from plasma of breast cancer patients have more significant levels of HER2 and epcam than those from healthy donors, suggesting the diagnostic potential of these markers for HER2 and epcam in breast cancer diagnosis. Breast cancer is a malignant tumor that occurs in the epithelial cells of the breast and is highly heterogeneous in time and space, and its extremely high incidence poses a serious threat to women’s physical and mental health and life safety . Zhang d3O4 @Ag-dnaau@Ag@DTNB (SERS tag) affixes. Early diagnosis of patients can be made by detecting differences in SERS signals in plasma-derived exosomes and residual supernatant plasma from pancreatic ductal adenocarcinoma (PDAC), chronic pancreatitis and normal control blood samples (in situ platform for direct extraction of exosomal miRNA from serum samples. They synthesized locking nucleic acid-modified Au@DTNB as a SERS tag into exosomes and assembled with target miRNAs to induce hotspot SERS signals. The exosomes were then enriched by the addition of Fe3O4@tio2 nanoparticles for further SERS detection. Using this technique to detect exosomal miRNA-10b can be used to effectively identify patients with PDAC (Pancreatic cancer is a highly aggressive and malignant malignancy of the gastrointestinal tract, and its incidence is increasing year by year . SERS wi samples . Jiang eith PDAC .Melanoma is a highly aggressive malignancy originating from melanocytes, the incidence of which is increasing every year . Fraire Osteosarcoma is the most common primary malignant bone tumor that occurs in the epiphysis of long bones, mainly in the distal femur, proximal tibia and humerus . ApproxiExosomes are found in a variety of body fluids, carry characteristic markers and play a wide range of functions . The stuin vivo analysis, where deficiencies such as background fluorescence, artifacts and weak signals need to be overcome and diagnostic models need to be constructed by multivariate statistical analysis methods before introducing Raman spectroscopy as a basis for diagnosis. Raman spectroscopy can analyze changes in diseases at the molecular level, providing objective and quantifiable information for disease diagnosis and evaluation of treatment efficacy. The use of Raman spectroscopy provides more insight into the infiltration process of tumors and the chemical information obtained allows quantitative and qualitative analysis of the disease. Interference such as fluorescence poses great difficulties in acquiring and resolving Raman spectra of biological samples, so there is still a need to develop techniques for acquiring, processing and classifying data to determine the nature of tumor tissue lesions by pre-processing the raw data, eliminating unwanted signals and enhancing Raman spectral features to achieve qualitative and quantitative analysis of the data. With the continuous improvement of Raman spectroscopy database, tissue classification methods and instrument design, it will become possible to acquire Raman spectroscopy data with higher resolution and accuracy and shorter acquisition time, thus enabling early cancer diagnosis. The reproducibility, reliability and sensitivity of SERS biological detection technology depend on the reasonable design of the SERS substrate, the proper handling of biological samples, the precise control of the detection conditions and the adequate analysis of the spectral data. In the future, efforts should be made to control its potential factors. We should prepare SERS substrates with high uniformity, high enhancement effect and clean surface, which can be modified appropriately. We can also choose appropriate Raman probe molecules to improve their biocompatibility, avoid non-specific adsorption, and to be tested In addition, when storing and pretreating biological samples, keep them in an environment close to the normal physiological state as much as possible to avoid irreversible changes. Moreover, select appropriate SERS detection conditions to obtain reliable detection information. More importantly, establish a standard SERS database of biomolecules to accurately identify spectral information. If necessary, the probe response in the detection system can be corrected, or appropriate data processing and statistical analysis methods can be selected. Future SERS technology The prospect in the field of early detection of tumor biomarkers lies in the development of an ultra-sensitive, highly specific, high-throughput and universal detection platform to meet the needs of life sciences and clinical diagnosis.There are still many challenges and limitations in using Raman spectroscopy to analyze biological samples. Higher sensitivity techniques such as SERS can be used when the Raman spectral signal of the sample is weak, but sample preparation plays an important role. When analyzing Raman spectra of biological samples, the complexity of the composition requires a reliable calibration model to ensure reliable and quantitative measurements. There are also challenges when using probes for In recent years, SERS technology has been applied to the study of exosome detection, which has greatly improved the sensitivity of exosome detection, which is significant for the development of new liquid biopsy techniques based on exosomes . The forWe reviewed the latest research and progress in the identification of exosomes by SERS in the early diagnosis of tumors. First, we discussed the current research status of SERS and the main detection methods of exosomes. Then, we summarized the exosomes detection strategies used to obtain the exosomes and unlabeled SERS signals, and classified and summarized the detection strategies according to how to capture exosomes on the SERS substrate. At the same time, we summarized the advantages and disadvantages of SERS in detecting proteins and nucleic acids. Moreover, we analyzed and summarized the research and progress of SERS identification of exosomes in the early diagnosis of different tumors, and proposed possible future research directions based on the current research status. With the further development of related technologies, we believe that the exosomes detection technology based on SERS technology is expected to become a new non-destructive, convenient and accurate liquid biopsy method for tumors.


To report a case of macular edema secondary to congenital retinal macrovessels (CRMs), which resolved spontaneously without any treatment.A 39-year-old female presented with blurry vision of the right eye for one day. Fundus examination revealed a branch of artery and vein of the inferior retinal arcade crossing the horizontal raphe. Optical coherence tomography (OCT) through the fovea showed cystoid macular edema in the outer plexiform layer. However, no leakage of the vessels was noticed by fundus fluorescein angiography (FFA). Observation was recommended with close follow-up. Two weeks later, the patient returned with good visual acuity, and the macular edema was resolved spontaneously.Macular edema is a possible complication of CRM by increasing retinal capillary hydrostatic pressure. Treatment is not necessary for this kind of macular edema if no leakage of the vessels is noticed on FFA. Congenital retinal macrovessels (CRMs) are usually unilateral, aberrant, large branches of retinal vessels crossing the horizontal raphe . These cA 39-year-old female presented with blurry vision of the right eye for one day. The best corrected visual acuity (BCVA) of the right eye was 20/25. She had no history of hypertension or diabetes, or any other systemic disease. The anterior segment in both eyes revealed no abnormal findings. Fundus examination revealed a branch of artery and vein of the inferior retinal arcade extending into macula with a sharp angle  Optos, . MacularThe prevalence of CRMs is approximately 1/200,000 . CRM rarMacular edema can be simply defined as an excess of fluid within the retinal interstitial space. The main mechanisms for keeping the retina in a dehydrated state are the presence of inner and outer blood-retinal barriers (BRBs) and the one-way movement of fluid across the retinal pigment epithelium (RPE) . The innIncreased vascular endothelial growth factor increases vascular permeability and promotes angiogenesis . IntraviIn conclusion, we described the clinical features of a rare CRM case with macular edema. The hydrostatic pressure change in these vessels is thought to cause macular edema. No anti-VEGF treatment is needed, and the macula edema can resolve spontaneously. However, long-term self-monitoring is recommended since the anatomic abnormality is permanent.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by The Second Affiliated Hospital of Zhejiang University School of Medicine Review Board and Ethics Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.Research was supported by Zhejiang Natural Science Foundation Project of China (No. LY18H120001), National Natural Youth Science Foundation Project of China (No. 31500795), and Zhejiang University Foundation Project (No. 2020-518052-0054).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Stroke is the second leading cause of death worldwide and fifth leading cause of death in the United States . The terKoutroulou et al. conducted a systematic review of studies investigating the PFO rates according to different diagnostic imaging modalities. They found significant heterogeneity with prevalence rates ranging from 24.2% in autopsy studies to 23.7% in studies using transesophageal echocardiogram for the diagnosis vs. 31.3% in studies using transcranial doppler and only 14.7% in studies using only transthoracic echocardiogram. As expected, PFO prevalence was higher among patients with prior cerebrovascular events vs. those without prior cerebrovascular events, across all different diagnostic modalities and the autopsy series.But what is the real prevalence of PFO? Ioannidis and Mitsias, in their state-of-the-art review, argue that PFOs can act as the direct cause vs. risk factor, or an even incidental finding in some patients with cryptogenic stroke. They provide an overview of the potential stroke mechanisms including paradoxical embolism, in situ clot formation or atrial tachyarrhythmias in the setting of a hypermobile atrial septum. Risk factors include the size and morphology of the PFO and the degree of the shunt. The authors present and explain the Risk of Paradoxical Embolism (RoPE) score and its use in patients with PFO. Low RoPE scores suggest low probability of pathogenic PFO and relatively higher probability of recurrent stroke events while higher RoPE scores suggest higher probability of pathogenic PFO but lower probability of recurrent events. The first of the mechanisms that Ioannidis and Mitsias proposed and analyzed is paradoxical embolism which originates from concomitant deep vein thrombosis (DVT). It seems that the prevalence of DVT and pulmonary embolism (PE) in those patients is higher than previously thought. Zietz et al. performed a systematic review of the association between DVT/ PE and PFO existence in patients presenting with cryptogenic stroke. They found eight eligible studies in total, with the DVT frequency ranging from 7 to 27% and the PE frequency ranging from 4.4 to 37%. They also examined the reversed association and they found that the presence of PFO in patients with PE was associated with higher rates of ischemic brain lesions. Given those findings, it is probably reasonable to maintain a lower threshold for DVT/PE screening in patients who present with stroke and are subsequently found to have a PFO.However, whether PFO (co)existence is the direct cause of stroke in patients with cryptogenic ischemic stroke remains an unanswered question. Ze-Jun Chen and Thijs. The authors included 14 studies and 13,425 patients comparing AF rates in stroke patients with PFO vs. those without a PFO. They found that patients with a PFO were 48% less likely to have AF compared to those without a PFO. Their results remained significant after performing separate analyses for cross-sectional and longitudinal studies and in different age groups (>60 years old vs. <60 years old). Those findings -although potentially subject to detection bias- support that patients with PFO are not at an increased risk of arrhythmia compared to the general stroke population and may actually have a lower risk. Impaired left atrial (LA) mechanical function has been suggested to be one of the possible causes of cryptogenic strokes, since it can be associated with blood stasis and thrombus formation, while a few studies have even associated impaired LA function with presence of PFO. Speckle tracking is one of the non-invasive methods to evaluate the LA function. Gazagnes et al. studied the association between LA longitudinal strain and presence of PFO in patients who presented with cryptogenic stroke. Interestingly, no association was found, even in the subgroup of patients with PFO and atrial septal aneurysm. Their results were probably limited by their small size and future studies are anticipated.On the other hand, the presence of PFO in the setting of ischemic stroke, was shown to be negatively associated with presence of AF, according to a meta-analysis conducted by Collado and Kavinsky discuss the need for a Heart-Brain team approach in PFO closure. The authors wrote a state-of-the-art opinion review presenting the relatively novel concept of the Heart-Brain team. They emphasize that after 2017, PFO closure for stroke preventions in young patients with prior stroke has resurrected and thus in order to avoid under-treatment or overenthusiasm about the invasive options, we should approach those patients with a multi-disciplinary Heart-Brain approach, including neurologists, general cardiologists and interventionalists among others. The Heart-Brain approach can probably provide the best possible consultation, decision making and outcomes for patients with PFO. Multidisciplinary discussion becomes of particular importance especially given the favorable outcomes even in the non-invasive, pharmacological arms of some of the RCTs and large registries on PFO closure. The explanation for this discrepancy might be explained by other non-PFO related risk factors for stroke which are concomitantly present in some of the patients who present with stroke and are found to have a PFO. In order to shed light into this theory, Kahles et al. analyzed data from the International PFO Consortium Study and tried to identify risk factors associated with prior stroke in patients with PFO. Their results were interesting suggesting that both PFO related (right-to-left shunt) and PFO unrelated  factors were associated with the likelihood of prior stroke and can potentially explain why there is heterogenous benefit among patients who receive a PFO closure device.The discussion for PFOs role in cryptogenic stroke and the utility of PFO closure for given patient subgroups is still ongoing. We hope that our guest issue provides new insights to the existing literature and creates questions that might be answered in the future.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Lessons learned from the blended offline/online approach to training and workshop facilitation are also explored in the paper.Small-scale pig farming is highly important to the economic and social status of households in Timor-Leste. The presence of an African Swine Fever (ASF) outbreak in Timor-Leste was confirmed in 2019, a major concern given that around 70% of agricultural households practice pig farming. This research used a virtual spatial group model building process to construct a concept model to better understand the main feedback loops that determine the socio-economic and livelihood impacts of the ASF outbreak. After discussing the interaction of reinforcing and balancing feedback loops in the concept model, potential leverage points for intervention are suggested that could reduce the impacts of ASF within socio-economic spheres. These include building trust between small-scale farmers and veterinary technicians, strengthening government veterinary services, and the provision of credit conditional on biosecurity investments to help restock the industry. This conceptual model serves as a starting point for further research and the future development of a quantitative system dynamics (SD) model which would allow  Small-scale pig farming plays a vital role within Timorese economic and social spheres. Across both urban and rural settings, over 70% of agricultural households raise pigs, with the average household keeping fewer than three pigs . Pigs arSince independence in 2002, Timor-Leste has made strides toward socio-economic progress as evidenced by steady rises in nominal income per capita (US$ 508 in 2002–US$ 1237 in 2018) and the Human Development Index (0.505 in 2000–0.626 in 2018). The economy remains largely dependent on oil and gas, which accounts for around 33% of total GDP, and finances 90% of the state budget . Most ofThe presence of an ASF outbreak in Timor-Leste was confirmed in September 2019. Before testing was scaled back due to COVID-19 restrictions, it had spread to eight out of 13 municipalities. Within 6 months of detection, nationwide mortalities had exceeded 50,000 pigs, around 11% of the national herd  approach to capture and model the multiple feedback effects within the pig value chain (VC) system, particularly the interactions between small-scale producers, household savings, disease outbreak, and the veterinary system. A unique advantage of SD approaches is that models of the system can be co-created with community members and other stakeholders through a well-documented process known as group model building (GMB) . In a reThis paper covers the process and tools used to pilot SGMB in Timor-Leste to understand the feedback loops and relationships that contribute to the socio-economic and livelihoods impacts of the recent ASF outbreak. A simple conceptual model of the socio-economic impacts of ASF within small-scale pig farming systems is presented. This concept model indicates several prospective feedback loops which drive behavior in the pig VC in Timor-Leste. Following a discussion on the interaction of reinforcing and balancing feedback loops, potential leverage points for intervention are suggested that could reduce the impacts of ASF within socio-economic spheres. Two critical innovations, one methodological and one practical, which enhance our knowledge of the livelihoods impacts of animal disease are also highlighted in the paper. First, to the research team's knowledge, participatory SD methods have not previously been used in Timor-Leste. The paper demonstrates that SGMB tools provide a simple and effective platform for VC actors to exchange perspectives and come to a common understanding on the key dynamic relationships which determine impacts in livestock systems. Second, the work in Timor-Leste piloted a hybrid online/offline form for participatory engagement given COVID-19 travel restrictions, which is elaborated upon in this paper as an example for future applications.ex-ante impact assessments of livestock sectors in countries such as Botswana   .Both SGMB and conventional GMB techniques lead focus group discussions through “scripts,” which are a set of guided activities aimed at achieving a specific objective in the facilitation and modeling process . The iniex-ante impact evaluation of potential intervention scenarios. The results of scenario-testing are then shared with stakeholders to support decision-making and encourage the ownership of recommendations  and the International Livestock Research Institute (ILRI) partnered with six staff from Veterinary Services within Timor-Leste's Ministry of Agricultural and Fisheries (MAF) and Menzies School of Health Research (MSHR) to conduct the field research. Due to COVID-19 travel restrictions, UQ and ILRI conducted online training and provided support for MAF and MSHR staff who facilitated the three face-to-face SGMB workshops in Dili, Timor-Leste with 13 participants from the pig VC. Ethical clearance  was obtained from UQ prior to conducting the research.https://zoom.us/) and utilized a range of online engagement tools, such as Padlet (https://padlet.com/), Jamboard (https://jamboard.google.com/), and Vecta (https://vecta.io/). Padlet is a document storage system which allows easy access to training materials and contained links to the Jamboard and Vecta web pages. Jamboard is a web-based platform operated by Google for real-time collaboration and brainstorming, providing a simple way of replicating a whiteboard online. It allows participants to write sticky notes and link/cluster them together by color or with freehand text in a shareable fashion with others in the workshop. Vecta is a free online editor for collaborative graphics editing. It mimics the participatory GIS features of Layerstack by including a feature whereby layers of information can be overlayed on top of one another. While training activities covered critical points of SD and SGMB theory, sessions were weighted toward the use of the tactile participatory modeling tools to build the skills and confidence of MAF and MSHR staff to facilitate critical elements of upcoming SGMB sessions.Training on SD and SGMB was conducted in June 2020 and led by ILRI team members. MAF and MSHR staff participated in six initial online training sessions of 90–120 min, covering: (i) an introduction to systems thinking and SGMB; (ii) how to plan an SGMB process; and (iii) how to use key SGMB tools . Training sessions were conducted online via Zoom (https://www.whatsapp.com/) voice and video technologies. Additional MAF staff joined these practice sessions to act as mock workshop participants. Further one-to-one coaching sessions were held with facilitators in the days leading up to the SGMB workshops to respond to questions around facilitation techniques of participatory tools.Following the formal training workshops, another two sessions were held to develop the agendas , pig traders (2) and veterinary technicians (3) also attended. The attending pig farmers were backyard producers, typically keeping between two to five hogs at any given time. Workshop dropouts came from pig trader and producer segments of the VC. SGMB workshop one and two were held on consecutive days and SGMB workshop three 9 days later which may explain the drop in attendance. Participant travel costs were reimbursed and they were provided with participation certificates from MAF.MAF and MSHR staff facilitated the workshops, playing the key SGMB roles of lead facilitator, assistant facilitator, and note taker. Additional roles were added to the in-country team given the blended workshop approach. A liaison/translator role was established to maintain a virtual connection with the team from ILRI who fulfilled the process coach roles. The liaison/translator would translate critical elements and act as the process coaches' “voice” into the workshop. This allowed researchers from ILRI to ask further questions and provide nuanced course correction during participatory exercises. During breaks in the workshop, the process coaches were able to speak directly to the lead facilitator, providing additional feedback and encouragement. Two video links between the process coaches and the workshop were maintained by way of a broad camera link that captured the entire workshop space (via Zoom) and a second handheld camera link (via WhatsApp) through which the liaison/translator could show details of workshop outputs, such as Layerstack maps. The modeler function was undertaken by a member of the ILRI team who also acted as one of the process coaches.The objective of the first workshop was to introduce SD and SGMB principles to workshop participants and to use Layerstack to understand the spatial dynamics of the pig VC and the socio-economic impacts of ASF. The hopes-and-fears exercise  at the sThe second SGMB workshop began with a recap of these two problems and an introduction to the basic terminology of SD  using the water-in-a-glass script . FollowiThe aim of the third SGMB workshop was to develop simple qualitative concept modules using basic SD terminology to capture participant understanding of the relationships in the pig farming system and the impacts of ASF. Concept modules are a qualitative tool that visually represents the most critical parts of any system  and capture dynamic complexity by documenting the polarity of relationships between stocks, flows, and converters, and the identification of feedback loops and time delays . FollowiAlong with the development of the concept model, the SGMB workshops helped frame the underlying problems and behaviors in the pig system in Tasi Tolu. Participants noted that there had been a steady decline in pig stocks in the target area over the last 5 years related to the application of a law that banned the free roaming of pigs in urban areas. Without the ability to let their pigs roam, pig farmers faced increased housing and feed costs. Pig feed mainly came from leftover household food and restaurant scraps. Piglets were usually purchased from within or nearby villages but there was no formal credit mechanism to help farmers restock after frequent disease outbreaks. Very few of the farmers had a relationship with the local veterinary technician (VT) and relied on traditional methods or medicine purchased from the local agricultural input supplier to maintain healthy pigs. None of the farmers present vaccinated their pigs. Farmers retained their pigs for traditional cultural purposes but also sold to neighbors and the local pork wholesale market when the household required cash. These pig sales typically comprise 20–30% of the household's yearly cash income. This supplements the other main livelihoods in the area of fishing, small livestock raising , operating small consumer supply shops, and selling of smoked fish and palm syrup. While income from other livelihoods would generally enable pig farmers to restock following a disease outbreak, the scarcity and high price of piglets and sows following the recent ASF outbreak had prevented many farmers from reinvesting. The ASF outbreak had also caused a high-level of mistrust in the system, as farmers were worried that they could not prevent or contain a future ASF outbreak nor could they verify the health of pigs and piglets flowing into their village.The SGMB participants prioritized two main problems in the pig system that exacerbated the current situation. First, there was a lack of technical veterinary services available to pig farmers. While there is a general standard of one VT per administrative post, it was acknowledged that this is insufficient to meet the requirements of farmers, with SGMB members suggesting village-level workers were necessary. Along with a lack of human resources, existing VT lacked transportation and communication equipment to conduct regular visits to villages. Some participants noted that government revenue from pigs was low and therefore this decreased the incentive to invest in support services. The second problem identified centered on the loss of household income from pig farming. With limited access to formal financial services and high prices, farmers were unable to invest in pig farming, robbing them of a vital safety net. Hogs were often kept and sold to cover lumpy household cash requirements, such as school fees and uniforms or investments in other livelihoods, such as purchasing new fishing equipment or stock for shops. Furthermore, hogs were required for cultural ceremonies like weddings and funerals. The lack of hogs and high purchase prices further exacerbated the loss of household savings and potentially alienated households from relatives who often form a reciprocal social safety net.The key output of the research process is a basic concept model of the pig system in Timor-Leste, as shown in The SGMB process identified prospective feedback loops that drive system behavior. These loops are denoted as “R,” Reinforcing or “B,” Balancing feedback loops in Changes in profits alter farmer willingness to invest in pig farming, which causes farmers to expand/contract the size of their pig farms through changing the number of breeding sows and the volume of piglets purchased. This affects the number of hogs sold and leads to further increases/decreases in farm profits.Changes in farm profits affect investments in pig feed, infrastructure , and the willingness of farmers to engage with (and pay for the services of) VT and MAF staff. This in turn impacts a farmer's application of biosecurity practices and the level of pig health, altering the pig mortality rate from diseases, such as ASF. Changes in mortality rates alter the proportion of pigs dying, affecting the number of hogs sold, leading to further changes in farm profits.Increasing investments in pig production and biosecurity/health investments lead to higher farm costs which lower profits and reductions in these investments.Trust between VT and farmers increases when they engage more frequently through trainings, field visits, and public awareness campaigns, and advice provided by VT increases farmer knowledge and improves pig health. As trust grows, farmers are more likely to report unexplained pig deaths to VTs, allowing earlier detection of ASF and the prompter application of farm biosecurity practices and adherence to movement restrictions between villages and regions. These lessen the pig mortality rate from ASF which results in higher farm profits and household savings, leading to higher post-ASF outbreak investments in pig production and an increased willingness of farmers to engage with VT and MAF staff. The increased trust also prevents the inappropriate use of antimicrobials, lessening farm expenditure and further increasing farm investments and trust with VTs and MAF.When hog numbers in a village decrease, farmers must increasingly purchase pigs for cultural purposes rather than using pigs from their own stocks. As pig stocks reduce this further inflates the price of purchasing pigs and the financial cost of cultural practices. Given the high cultural value placed on pigs, there is a delay between the rising costs of cultural practices and reduced participation in cultural ceremonies. Until this point is reached, purchasing pigs for cultural practices increases household expenditure and draws down household savings, reducing the ability of farmers to reinvest in pig farming and furthering lowering the overall number of hogs in the system.When household savings fall and the price of live pigs increase, at some point, households lessen their participation in cultural ceremonies involving the use of pigs or other livestock. The reduction in demand to purchase pigs for cultural ceremonies causes stocks of hogs to rise. This lowers the price of live pigs, reducing the financial costs associated with cultural practices and increasing household savings which leads households to start participating in cultural ceremonies again.When farmer participation in cultural ceremonies falls, there is a loss of face and less contact time between family members. As a result, the likelihood of misunderstanding and conflict with extended family members rises, and household social status falls, both of which decrease the ability to depend on extended family members for support. This lessens the ability of households to generate income from other livelihoods or meet regular household needs through gifts-in-kind or cash provided by extended family members. This reduces the stock of household savings and further limits the household's ability to participate in cultural ceremonies.When the number of hogs in one geographic location decreases, people purchase hogs from another village/region for cultural practices, increasing the movement of pigs across the country. This growth in movement raises the rate of spread of ASF across Timor-Leste, leading to further pig deaths and a shortage of hogs.As household savings decrease, the household's ability to purchase nutritious food, healthcare, and education fall which, after some time, will negatively impact their ability to generate earning, thereby further reducing household savings.As the number of hogs in the system decreases the price of live pigs rise, incentivizing investment in pig farming. This increases the number of hogs in the system and diminishes the price of live pigs.The concept model of the pig VC allowed the identification of potential leverage points to help mitigate the socio-economic impacts of an ASF outbreak in Timor-Leste. Leverage points are parts of the system that, when changed, can multiply positive impacts through the rest of the system by their ability to influence critical feedback loops.Firstly, trust building between small-scale pig farmers and VT is a possible catalytic intervention. The concept model shows that increased trust and connection points assist prevention, reaction, and recovery from an ASF outbreak. In the R3: Trust loop, repeated farmer engagements with VTs and MAF increases farmer technical knowledge, fuelling investments in quality feed, improving biosecurity practices, and strengthening the use of appropriate antimicrobials. Along with repeated exchanges, the quality of the services provided by VT and MAF also strengthens trust. When increased knowledge and investments in good animal husbandry practices result in noticeably lower pig mortality rates, farmers strengthen their links with VTs and MAF, reinforcing knowledge gains and farm investments (R1 and R2).As trust and connection points grow with MAF, small-scale pig farmers are more likely to report pig deaths and adhere to movement restrictions during outbreaks, working to decrease the mortality rate. The promotion of pig producer groups (PGs) as a possible intervention strategy can facilitate this process as they can foster adherence to group biosecurity rules, peer-to-peer learning, and lower monitoring costs for MAF . A high Secondly, strengthening the capacity of MAF to provide effective services will further increase trust in the system. This entails having enough VTs to ensure pig producers can access applicable training, quality veterinary services, and timely information on disease outbreaks and preventative measures. The perceived and actual quality of services plays a critical role as pig farmers' trust and engagement depends on the perceived benefit of VT services  outweighing time and financial costs. Strengthening MAF services operates directly on feedback loops R2 , which is countered by B1 (increasing costs) to determine if the R1: Farm investment loop operates in a virtuous manner which stimulates the R3: Trust loop. Increasing MAF capacity comes at a cost to the government of Timor-Leste as funds would need to be diverted from other government priorities. To ensure sustainability of MAF services and continuing activation of the R3 loop, institutional arrangements and fee gathering mechanisms that can lessen the financial burden on MAF should be investigated. Examples that could be considered (and later modeled) include PGs, Village Livestock Workers, and co-payments for VT services.Lastly, following an ASF outbreak, support should be given to help pig producers restock their farms. Start-up loans or cash grants could be provided to small-scale pig farmers conditional upon application of farm biosecurity practices. In this system, the strong demand for live pigs for cultural practices may keep the price of restocking pig farms beyond the financial ability of the poorest small-scale farmers, particularly those who exhausted household savings due to the presence of the R4: Providing hogs for cultural purposes loop. Even when the B2 loop is activated, and farmers reduce their participation in cultural practices this may further exacerbate the R7: Poverty Spiral loop as the R5: Social capital loop may have caused a reduction in household savings. Providing microloans or cash grants to restock pig farms could help to stabilize live pig prices, lower the costs of cultural practices, and steady social capital stocks. Importantly, loans or grants would also ensure the B3: Restocking loop is activated, increasing the scale and diversity of small-scale farmers who re-engage in pig farming. If these loans or grants are made conditional upon investments in biosecurity practices and attendance at VT training, they would lower the susceptibility of the pig industry to future disease shocks and help activate the R3: Trust loop. Microfinance loans have been criticized for delivering modest pro-poor outcomes, potentially causing over-indebtedness, and delivering mixed performance in the SME sector . MoreoveThe blended offline and online nature of the SGMB workshops necessitated by travel restrictions was unique to this study and several lessons emerged that can be applied to similar processes in the future. The offline, tactile SGMB tools encouraged strong levels of participation from a diverse set of stakeholders and information surfaced in discussions which was new and pertinent to the MAF team. SGMB exercises follow in the rich vein of easy-to-understand participatory rural appraisal (PRA) methods  with theThe use of two video links helped the remote process coaches guide the facilitation of the SGMB exercises. The broad video link capturing the dialogue and interactions amongst workshop members helped gauge the level of participation and acceptability of the tools . Meanwhile, the focused video link was controlled by the translator/liaison, meaning it could be directed to an area of interest in the workshop  at the discretion of the process coaches.While there was little hindrance in remote workshop observation , it proved more challenging for remote process coaches to interject and help steer the workshop in real-time. This was partly due to the time delay in relaying messages through the translator/liaison to the workshop facilitator as well as the language barrier of communicating between Tetum and English. The translator/liaison role was essentially overloaded as the individual had to perform multiple tasks: videorecording the session, translating the workshop dialogue from Tetum to English, communicating with the two process coaches, and then digesting messages to then help coach the facilitator or ask a question to the plenary. As workshops extended into the 5-h mark, this became an exhausting process. For future virtual workshops, it would help to have one member of the facilitation team act as a pure translator who also managed the second video link and then an additional individual as the liaison between the process coaches and the facilitator.The SGMB workshop exercises consistently went over time and the last exercise from workshops one and two had to be moved to the following session. This shortened the time available to develop concept modules  and did not allow review and consolidation of the concept modules by the modeler between workshops two and three. Delays during the workshop could be overcome through better workshop preparation  and less repetition of exercise explanations. However, the nature of virtual process coaches and a first-time facilitation team meant delays were, to an extent, unavoidable. For example, compared to face-to-face facilitation, cues such as body language and participation levels could not be as quickly interpreted, and translations and explanations had to pass through an additional channel (the translator/liaison). Future processes should allow for the additional time required for a blended workshop approach and contain additional workshop sessions. Extra spacing between workshops would also help ensure that the large volume of workshop information collected could be translated and analyzed between workshops and further team members (beyond the lead facilitator) could have an opportunity to prepare with the process coaches. Another option would be to reduce the amount of material covered in each session, having more frequent but shorter duration workshops of 2–3 h. This latter option would have also helped prevent participant fatigue and the higher dropout rates when workshops are spread over several weeks.The advantages of SGMB over conventional GMB highlighted in this research mirror those observed in Rich et al.  in TaninA number of limitations within this research should be noted as they impact the model's results and applicability to the wider pig industry in Timor-Leste. Literature suggests that participatory processes can be biased toward community members who already wield power , prove eThis first-time application of a blended, hybrid online/offline SGMB process in Timor-Leste resulted in a rich conceptual model of the socio-economic and livelihood impacts of ASF in Timor-Leste. While there were additional challenges from the virtual nature of training, coaching, and session facilitation, the resultant model highlighted critical feedback loops which explain system behavior during an ASF outbreak that other animal health impact assessments have not explored. This led to the identification of potential leverage points for intervention by the government of Timor-Leste and development partners.The next step in the process is to share the concept model for feedback with stakeholders in Timor-Leste, including SGMB participants and MAF staff to ensure the current structure  accurately represents the system. The concept model was developed using Tasi Tolu as the model boundary, meaning the model and leverage points are influenced by the peri-urban context, i.e., improved access to services, and a restricted group of VC stakeholders. The verification and feedback process would require a wider group of stakeholders to agree that the model and scenarios are representative of the wider country. Once consensus is reached on the basic structure, the concept model could be expanded into a full quantitative SD model. This would require parametrization of the model variables and additional structure to support scenario-testing. As showcased in the paper, the qualitative concept model provides insights into possible leverage points in the system; however, a quantitative SD model would allow a fuller range of scenario-testing of potential interventions and trade-off analysis in terms of impacts across VC actors, time horizons, and resource constraints . For example, the impact of start-up loans/cash grants on small-scale farmers could be compared against investments in training and expansion of VT or the introduction of charges for VT services. This would enable a cost-benefit analysis of standalone interventions along with intervention combinations to investigate multiplier effects. A quantitative model would also provide insight into potential negative consequences of interventions, or trade-offs that might exist across the VC nodes or impact dimensions  , 21, 26.The concept model presented in this paper and a future quantitative model could be readily adapted to other areas of investigation in Timor-Leste as further modules are developed and linked. For instance, the household cashflow model can be expanded so that links between investments in the pig VC and household expenditure on healthcare, education, and nutrition can be considered as part of the decision-making on intervention options. Once a robust SD model of the socio-economic and livelihood impacts of ASF in Timor-Leste is constructed and validated, it can be adapted to other contexts and requirements. The high economic and cultural value placed on pigs  and the The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The research received ethical clearance from the University of Queensland Institutional Research Ethics Committee . Informed consent was obtained from all human subjects. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.TC, DS, KD, and KR conceived the study. JB, KD, and KR trained the research team and developed the methodology and analyzed the data. AP, JB, JoB, KD, KR, and OM collected the data. JB wrote the first draft of the manuscript. AP, DS, JoB, KD, KR, OM, and TC reviewed and edited the final manuscript.The research was undertaken within the ACIAR-LS/2019/187 Small Research Activity, Developing a Regional African Swine Fever Socioeconomic and Livelihood Impact Assessment Framework, funded by the Australian Government's Australian Centre for International Agricultural Research.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 reviewer TSB declared a shared affiliation, though no other collaboration, with several of the authors TC and DS to the handling editor. The reviewer TSB declared a past co-authorship with one of the authors OM to the handling editor.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Metoposaurus krasiejowensis have mostly focused on shoulder girdle elements and the skull. So far, histological data on the mandible are still scant. For the present study, two mandibles have been examined, using 50 standard thin sections. Dermal bones of the mandible reveal a uniform diploë structure, with the external cortex consisting of moderately vascularised, parallel-fibred bone, as well as a distinct alternation of thick zones and thinner annuli. Dense bundles of well-mineralised Sharpey’s fibres are seen in the external cortex over the entire length of the mandible. The trabecular middle region is highly porous and well vascularised, showing small primary vascular canals and more numerous secondary osteons; irregular erosion spaces occur in large numbers as well. The thin and poorly vascular internal cortex consists of parallel-fibred bone. The articular is not a dermal bone in origin, having been formed of a thin layer of avascular cortex and a very extensive, trabecular middle region. In contrast to the dermal bones of the mandible, the articular developed from a cartilaginous precursor, as evidenced by numerous remains of calcified cartilage in the central parts of the bone. Histological variability is extremely high along the mandible, its anterior part being characterised by high compactness and biomechanically good resistance in contrast to the highly porous posterior parts. Distinct variations of bone thickness and degree of bone porosity in specific areas of the mandible, may be due to local differences in biomechanics during feeding. The microstructure of the mandible corroborates a previous study of the active and ambush predation strategy in metoposaurids.Recent studies that have systematically augmented our knowledge of dermal bones of the Late Triassic temnospondyl amphibian  Histological analysis that focuses on the sections of single bones may provide a prediction of overall bone biomechanics  allow us to conduct histological analyses in a much more detailed way than is usually the case. Histology is an invasive research method; thus, it cannot be used when fossil material is rare or valuable. Generally, such studies are carried out on the basis of several thin sections at best. However, detailed investigations of serially sectioned pieces from a single individual have never been conducted previously for any vertebrate taxon.Thus, the presentation of detailed histological characteristics of serially sectioned mandible bones may allow not only for a better understanding of metoposaurid palaeoecology in Late Triassic ecosystems, but also provide a solid basis for other research techniques. The goals of the present study are threefold: (1) to document, for the first time, the mandible histology on the basis of serially sectioned specimens; (2) to compare the histological variability of mandibles of two conspecific individuals, and (3) to provide a preliminary interpretation of mandible biomechanics based on our histological framework.The material examined comes from an abandoned claypit near the village of Krasiejów in the Opole voivodship . Geologically, this region is located along the south-easterly edge of the Fore-Sudetic Homocline and sedimentary strata at Krasiejów are of Late Triassic-Norian age, based on stratigraphical data  or CarniMetoposaurus krasiejowensis have been analysed histologically; both specimens are stored in the collections of the University of Opole, Institute of Biology, Laboratory of Palaeobiology (abbreviation: UOPB). UOPB 01145 is a complete (38 cm in length), well-preserved left ramus  in order to compare the histological variability between the two specimens.In total, 50 transverse thin sections of the mandibles of specimen . UOPB 01SiC grinding powders . Microscopic observations were conducted using a LEICA DMLP light microscope in plane and cross-polarised light and with a gypsum filter, and were supplemented with a scanning electron microscope (SEM) Hitachi S-3700N and binocular microscopes Olympus SZH10 and SZ61.Thin sections were prepared at the Institute of Geology, Adam Mickiewicz University . Following standard petrographical procedures , thin seMetoposaurus were assessed and compared to results of previous work on the cranial bone histology of this taxon  possess variable shapes along their length. In many places they become U-shaped in cross section; thus, recognition of the position of external and internal cortices may be difficult. In the present study, it is assumed that term ‘external cortex’ refers to parallel-fibred bone which occurs in the uppermost and ornamented parts of the bones on the labial side and similarly in the uppermost and unornamented parts of the same bones on the lingual side. Conversely, ‘internal cortex’ refers to parallel-fibred bone which comprises the opposite and unornamented margins of bones, both on the labial and lingual side. To avoid confusion, we use the term ‘growth marks’ in relation to lines of arrested growth (LAGs), resting lines, zones and annuli , and interwoven structural fibres (ISF), which indicate the metaplastic origin of dermal bones , bone porosity was calculated using the pixel-counting software ‘bw-counter’ developed by Peter Göddertz at the Institute of Geoscience of the University of Bonn . All cross sections are considered to represent a single sample record, without distinction of individual bones. Only the articular, visible in the two final sections, was invariably calculated separately because of the different origin and structure.For the most representative cross sections used herein  could not be found , dermal bones also represent a diploë combination in cross section. External and internal cortices usually consist of a compact layer of parallel-fibred bone , both types of Sharpey’s fibres are present as well. However, long and short fibres occur together along the whole length of the mandible on the labial side  for stress resistance. Another example is the squamosal, sectioned in its anterior part and next to the otic notch, which showed different histological levels. Bones situated on the palatal side  display weaker biomechanical resistance, characterised by a low bone thickness and extreme porosity  which varies in other parts of these bones  between them (vs. compression) have been noted along the mandible  which was helpful during feeding activity. In contrast, in the posterior and articular areas of the mandible only compression-resistant sutures have been noted. Such suture types combined with a large number of long Sharpey’s fibres may have reinforced and compensated for the relatively weak microstructure of those bones.The general histology of the mandible of Metoposaurus krasiejowensis with other temnospondyl taxa. However, it cannot be ruled out that in temnospondyls with an analogous morphology of the mandible , their general histology and biomechanical role was similar. Thus, results presented here and in previous papers on mandibular sutures in Metoposaurus krasiejowensis, constitute a solid basis for future histological and computational studies.In summary, the histology of the mandible presented herein corroborates and significantly supplements earlier histological and computational FE investigations into the ecology of metoposaurids. Moreover, we present the first description of dermal bone microanatomy of serially sectioned specimens. Based on previous works, we know that these temnospondyls specialised both in active and ambush predation. The bone microstructure and morphology of the sutures suggest that the skull was used for lateral or bilateral biting, whereas the mandible played a role in holding down any struggling prey. Due to a lack of histological data of the mandible in early tetrapods, it is difficult to compare the results scored for