Drug-induced liver injury (DILI) remains a major cause of drug development failure, post-marketing warnings and restriction of use. An improved understanding of the mechanisms underlying DILI is required for better drug design and development. Enhanced reactive oxygen species (ROS) levels may cause a wide spectrum of oxidative damage, which has been described as a major mechanism implicated in DILI. Several cell-based assays have been developed as in vitro tools for early safety risk assessments. Among them, high-content screening technology has been used for the identification of modes of action, the determination of the level of injury and the discovery of predictive biomarkers for the safety assessment of compounds. In this paper, we review the value of in vitro high-content screening studies and evaluate how to assess oxidative stress induced by drugs in hepatic cells, demonstrating the detection of pre-lethal mechanisms of DILI as a powerful tool in human toxicology. Drug-induced liver injury (DILI) is triggered by prescription and non-prescription drugs, as well as herbal products or dietary supplements, leading to liver impairment or damage, and in the worst case liver failure ,2. DILI Several hundreds of drugs have been associated with liver damage and the list is ever-growing . For a fIt has been reported that DILI can be a multistep and multicellular disease process with a wide range of chemical etiologies. Thus, a better understanding of the mechanisms underlying DILI is essential in order to evaluate current strategies for the detection of hepatotoxicity . SeveralDuring the past years, numerous in vitro systems have been described in the literature in an attempt to advance the understanding of the underlying mechanisms of human DILI ,9. TheseAdditionally, readout technologies have also evolved from single mechanistic endpoints toward approaches that consider global changes produced by drugs. In this sense, toxicologists have begun to apply newer technologies including toxicogenomics, metabolomics and high-content screening (HCS) assays . HCS assIn this paper, we review the use of in vitro HCS to assess oxidative stress induced by drugs in hepatic cells, demonstrating the detection of pre-lethal mechanisms of DILI as a powerful tool in human toxicology.DILI is a complex multistep phenomenon which encompasses a wide spectrum of clinical presentations and may mimic any form of liver disease  . MechaniThe liver is recognized as a frequent target of toxic damage due to its anatomic location and its high content of drug metabolizing enzymes. Most orally administered drugs are metabolized in the liver before they reach other tissues. Although for many drugs metabolism renders non-toxic metabolites (detoxication), some drugs may undergo metabolic bioactivation, with the generation of reactive metabolites able to induce liver injury. Thus, the parent drug itself, or more often any of its metabolites, may directly induce a chemical insult to hepatocytes or may eventually initiate a series of processes  which contribute to the progression of liver damage .Drug metabolism reactions, in particular oxidations by CYP enzymes, play an important role in hepatotoxicity. Reactive metabolites generated during drug bioactivation may covalently bind to macromolecules to form adducts with DNA or proteins . CovalenMitochondria play a pivotal role in the maintenance of energy metabolism, the integration of cell signaling pathways and the mechanisms of cell death. Thus, the alteration of mitochondrial homeostasis is a common cause of cell damage induced by drugs or their metabolites . InhibitROS are highly reactive molecules formed as a by-product of aerobic metabolism. They participate in diverse cell signaling pathways and modulate cell growth and metabolism . DisturbOxidative stress results from an imbalance between the generation of oxidant species and the antioxidant capacity of the cells. This situation is produced under different pathological conditions, including exposure to drugs that induce an excessive formation of ROS or a depletion of antioxidant defense systems .N-acetyl-p-benzoquinone imine (NAPQI), a reactive metabolite which depletes GSH, especially in mitochondria [Although most electrons provided to the MRC are safely transferred to molecular oxygen to form water, direct or indirect impairment of the MRC by chemicals increase the occurrence of single-electron reductions of oxygen in the mitochondria to form ROS, mainly in the form of superoxide anions. The activity of superoxides dismutase and glutathione peroxidase, enzymes known to play important roles in the detoxification of ROS in the mitochondria, can be overtaken in some stressing circumstances. For instance, acetaminophen overdose leads to the formation of chondria . Thus, mchondria . An excechondria ,19.In addition to drug-induced disruption of the MRC, ROS can also be generated during metabolism of drugs by CYPs and other oxidative enzymes or by the presence of compounds that undergo repeated redox cycles. The formation of reactive intermediates by drug-metabolizing enzymes is involved in the hepatotoxicity of many compounds . Most reDrug metabolism may also induce the formation of ROS or other radical species derived from oxidative or reductive metabolism of the drug. Oxidation of azathioprine (AZA) and other thiopurine drugs by xanthine oxidase has the potential to generate ROS that may result in liver damage via GSH depletion and mitochondrial injury . CertainMultiparametric measurements of HCS assays are very useful in early toxicity and safety assessment in drug development. HCS technology, which allows automated image acquisition and analysis and provides information on multiple properties of individual cells loaded simultaneously with fluorescent dyes or transfected with fluorescent reporters, is used for drug safety evaluations. One of the main advantages of HCS technology is that distinct endpoints can be measured at a single-cell level simultaneously. A typical HCS assay for the detection of toxicity includes: (i) the selection of a relevant cell model; (ii) incubation with model test compounds; (iii) staining with a combination of fluorescent probes indicative of cell damage, and (iv) automated image acquisition and analysis using HCS equipment. Different ex vivo and in vitro models have been used in HCS assays, from isolated primary hepatocytes to complex 3D models. Immortalized human cell lines such as HepG2 or HepaRG cells have been widely used for toxicological assessments as substitutes for PHHs in drug screening ,34. PHHsThe second step of an HCS assay for toxicology studies includes incubation with test compounds. In this phase, appropriate positive and negative controls may be properly selected to ensure that the assay allows the detection of the desired endpoint. These controls should be run in every set of experiments. Moreover, it should also be considered that some compounds can be autofluorescent and could interfere with some of the selected fluorescent probes.HCS enables the multiplexing of the information that is obtained in a single assay, by using a combination of fluorescent probes. The major requirement for the use of multiple probes is their optical compatibility and the limitations of the instrument used for the measurements . SectionAfter incubation with fluorescent probes, the automated acquisition of fluorescent images in separated channels is performed. Microscopy performance is usually assessed based on three criteria: sensitivity, resolution and speed . It is iDue to the large numbers of images that are generated in HCS assays, automated image processing and analysis are decisive for large-scale image-based toxicity screenings. As a first step, in order to reduce noise and correct background or illumination, image-processing algorithms are used . SecondlData analysis and management in HCS has advanced significantly in the past years, since the large volume of data produced in HCS assays is commonly a bottleneck in many projects. It should be considered that processing hundreds of images by applying image algorithms requires a powerful infrastructure . MoreoveAs ROS production is a major mechanism implicated in DILI, several fluorescent probes have been described for their use in toxicological studies. Fluorescent probes can simply detect ROS production in general or in specific radicals or locations. 2O2 [2DCFDA enters a cell, its acetate moieties are cleaved by intracellular esterases, resulting in an impermeable H2DCF form. Subsequent oxidation of H2DCF produces the fluorescent 2′,7′-dichlorofluorescein, which can be detected in the green spectrum [For instance, the accumulation of the fluorescent compound 2′,7′-dichlorofluorescin (DCF), generated by intracellular oxidation of DHCF-DA, was used as an indicator of ROS generation, mainly H2O2 . Once thspectrum .Monochlorobimane (mBCl) is a membrane-permeant probe that fluoresces in the UV spectrum upon reacting with GSH in a reaction catalyzed by the enzyme glutathione-S-transferase . Due to ® Oxidative Stress Reagents are fluorogenic probes designed to detect ROS in live cells. The CellROX Deep Red signal is localized in the cytoplasm of the cells and it has been used in several HCS assays for the detection of acute [CellROXof acute  or repeaof acute .On the other hand, dihydroethidium (DHE), also called hydroethidine, dye is oxidized to fluorescent ethidium, which intercalates into DNA; the fluorescent signal is used as a measure of oxidative stress . DHE exhLipid peroxidation, as a measure of oxidative stress damage, can be detected with the lipophilic probe, BODIPY 665/676 dye. This probe exhibits a change in fluorescence after interaction with peroxyl radicals .Mitochondrial superoxide production can be identified by measuring MitoSOX Red fluorescent intensity in the mitochondrial compartment . It has Other researchers have used HCS in reporter-cell lines. In this case, it is based on the use of a bacterial artificial chromosome containing a genomic copy of a particular gene and a fluorescent luciferase reporter construct introduced by homologous recombination . Major cMultiple HCS assays have included fluorescent probes for the detection of oxidative stress damage induced by drugs, since oxidative stress is one of the major mechanisms implicated in DILI. For instance, we have demonstrated that HCS can be used for the detection of oxidative stress damage. Many groups have used HCS for the detection of oxidative stress induced by drugs. 2DCFDA and mBCl, respectively, as fluorescent probes [One of the first descriptions of the potential of HCS for the evaluation of DILI was the measurement of mitochondrial damage, oxidative stress and intracellular GSH levels in PHHs using TMRM, CM-Ht probes . PHHs weWe have also included oxidative stress in our panels covering different mechanisms implicated in DILI ,45. We fMennecozzi et al. (2015) investigated sex-specific differences in PHHs from different donors exposed to hepatotoxic drugs using HCS. They used a combination of probes which included DHE for ROS production. Differential effects in oxidative stress damage were detected depending on the compound assessed, although a general pattern could not be defined for female or male hepatocytes .2DCFDA for ROS production and mBCl for GSH depletion. Additionally, they pointed out differences in drug metabolism due to the significant differences between both cell models in GSH depletion, indicating the value of HCS assays for DILI screening and also for studying the contribution of metabolism to hepatocyte toxicity [A comparative study of HepG2 and HepaRG cells for the prediction of DILI demonstrated that DILI compounds, which deplete GSH via reactive metabolites, showed a more significant decrease in GSH or increase in ROS in HepaRG than in HepG2 cells . This sttoxicity .2DCFDA for the measurement of ROS and showed that ROS production was one of the most sensitive parameters for the detection of drug-induced toxicity, pointing out the suitability of this probe for the study of DILI in vitro [Since current in vitro test systems have different limitations for toxicological studies, other cell-based models, including stem cells differentiated into a hepatic phenotype, are being explored as a functional source of human hepatocytes. HLC-derived iPSCs have been used to evaluate the hepatotoxic potential of well-known drugs at subcytotoxic concentrations by means of HCS . The autin vitro .On the other hand, the monitoring of adaptative stress response pathways has also been used as a predictive tool in toxicology ,57. WinkFinally, HCS has been also used for the evaluation of the effects of natural products in hepatic cells, demonstrating the suitability of this tool for assessing both oxidative stress induction  and the HCS may be used in the pharmaceutical industry to screen candidate drugs for potential human toxicity, to rank and select lead compounds and to demonstrate the major mechanisms of toxicity . HoweverThe high financial investment required to bring a drug to the market, along with the high rates of attrition of new molecules, make necessary the optimization of screening procedures for more efficient evaluations of drug safety. Human cell models are increasingly used in preclinical safety testing, as they provide quick and relatively inexpensive information in the early phases of drug development. As previously stated, the mechanisms responsible for DILI are poorly understood, which complicate the establishment and validation of predictive screening tools and limit the reliability of in vitro toxicity testing. Traditional tests rely on the determination of unspecific endpoints indicative of overt loss of cell integrity and have been shown to be insufficient to predict the hepatotoxicity of many drugs. Multiparametric HCS or omics-based approaches have gained popularity for hepatotoxicity studies as they enable the simultaneous determination of multiple informative parameters that may contribute to more accurate DILI predictions. In particular, HCS allows for the simultaneous analysis of several markers of cell damage and enables the detection of subtle toxicity-related changes with greater sensitivity than conventional single-endpoint cytotoxicity assays.The flexibility of HCS technology allows researchers to easily adapt assays to multiple applications by selecting the most appropriate cell model and fluorescent probes. HCS has been proven as a valuable screening tool for the identification of hepatotoxic drugs in diverse cell models . Cell-based HCS assays have been evaluated and validated in the toxicological field not only for the study of hepatotoxicity but also for neurotoxicity, cardiotoxicity and nephrotoxicity applications . A carefOne potential limitation of traditional monolayer cell systems used in hepatotoxicity evaluations is the loss of the native 3D microenvironment of liver cells. Recent technological advances have allowed the development of more complex in vitro models that better reproduce the spatial organization and inter-cellular interactions in the liver . 3D cultThe widespread application of HCS assays to the study of oxidative stress induced by drugs could provide fast, sensitive and accurate safety evaluations in early drug development. Cell-based HCS tools could also enhance the understanding of mechanisms and pathways involved in oxidative cell damage and could contribute to the identification of drugs, natural products or foods with antioxidant capacity.


The helminth and arthropod parasite communities occurring in macropodid, vombatid and notoryctid marsupials as well as in rodents in the arid zone of Australia are compared with those found in related host species in adjacent semi-arid and humid zones and are also related, where possible, to the changes in the mammalian fauna of central Australia over a geological time scale. Across the marsupials and rodents for which parasitological data are available, there is an obvious contrast in the helminth communities between inhabitants of high rainfall areas and those inhabiting semi-arid and arid zones in terms of parasite genera present in the marsupials. The differences between the inhabitants of semi-arid and arid environment communities are less overt and are observable only the parasite species level in the case of the kangaroos and wallabies. In the case of the rodents, there appears to be a significant lack of diversity in helminth faunas associated with the transition to an arid environment. Differences in the arthropod parasite communities between climatic regions are more marked than is the case with the helminths. The general lack of life cycle studies of these parasites provides an impediment to identifying the means by which they have adapted to the increasing aridity in central Australia over geological time, but appears to offer opportunities for future study. Petrogale xanthopus, the yellow-footed rock wallaby: an inhabitant of arid inland areas of eastern Australia. •Not really applicable to review articles. The latter is approached by comparing the parasites of specific mammalian inhabitants of the arid zone with those of related species in adjacent semi-arid zones and the humid zones, with the humid zones being essentially coastal in their distribution.2The Australian continent is divisible into a number of zones based either on biotic regions  or on a 3The original mammalian inhabitants of central Australia appear to have been rain-forest dwelling marsupials including macropodids  and vombatoids (wombats and their relatives) . These wMelomys, Uromys) remain as rainforest inhabitants in eastern Australia, other genera  have apparently adapted to and diversified in the arid conditions of central Australia  were restricted to arid Australia. No possums, pygmy possums, gliders  or koalas (Phascolarctidae) occur in this region today. Lasiorhinus latifrons) is restricted to arid and semi-arid habitats  while recent taxonomic changes, particularly to the rock wallabies , slightly increase the number of species and races restricted to central Australia   was documented by habitats . Some ofteralis) . In additeralis) . The datteralis)  allowingteralis) . However4The extent of knowledge of the helminths of Australasian marsupials and monotremes was reviewed by 5Thylogale spp.) which are found in the tropical and sub-tropical rainforests of the east coast of Australia as well as in the temperate forests of Tasmania (Dendrolagus) also occur in the tropical rainforests, but these are a more recent evolutionary development (Macropus giganteus (eastern grey kangaroo) and M. fuliginosus (western grey kangaroo). Both species occur not only in the high rainfall coastal zones, but are also common in the intermediate semi-arid zones of Osphranter rufus) and the euro (Ospharanter robustus erubescens). The distribution of O. rufus appears to be limited by mean annual rainfall and mean annual temperature Thylogaleustralia .Fig. 2GeThylogale spp.), coastal regions of high rainfall and the semi-arid landscapes (Macropus spp.) and those occurring primarily in the arid zone (Osphranter spp.), although there is considerable overlap in the distributions of latter two genera.A review of the helminth parasite faunas of these species allows some comparison between macropodid species inhabiting either coastal rainforests  occurring on the Australian mainland in rainforest areas along the eastern coast have a highly diverse helminth community with 40 species of nematodes and six species of cestodes  is restricted to these hosts  while in other macropodid hosts species ‘flocks’ of Cloacina are generally present   .Table 2CM. fuliginosus and M. giganteus, occupy forests and grasslands in the high rainfall zones, but extend conspicuously into the semi-arid zones fringing the central arid zone and extend to a limited degree into the arid zone itself  which can be present in very large numbers  in M. fuliginosus, and 200 to 268, 000  in M. giganteus; Cloacina species, with 15 species recorded from M. giganteus and 14 from M. fuliginosus, many of which are shared between these two host species  by O. rufus is diverse  and in the non-tropical parts of its range is dominated numerically by R. australis in the stomach, again frequently in large numbers ; Zoniolaimus ; Cloacina specific to or primarily parasitic in O. rufus .Of the two large macropodid species found in the arid zone, the helminth parasites of the red kangaroo, O. robustus were considered at the species level by O. r. robustus . Rugopharynx australis is also present in 32% of animals, but mainly in the southern part of the host range  was 67%, while the similarity between the northern wallaroo, O. r. woodwardi, and O. r. erubescens was 55%  are not monophyletic but rather are scattered through the clades of genera belonging to the Cloacininae and therefore that phylogenetic associations may not be the dominant determination of these distributions. No comparable information is available for the cestodes.Comparing the helminth communities of these macropodids, it appears that the major difference between rainforest inhabitants and the grazing macropodids is a change in the nematode genera present from one dominated by endemic genera in the rainforest inhabitants, with few species of  to date  suggest Differences between the forest-grassland-dwelling grey kangaroos and the arid zone red kangaroos and euros appear to be much more subtle and are more likely to be reflected in the species present rather than in the genera. Consequently, these differences are explored in greater detail.Rugopharynx australis and the closely related species R. macropodis are the most abundant nematodes in both the grey kangaroos and the red kangaroo respectively. Until recently, both species were included within R. australis Rugophary species  and the midities . Similarid areas   in higher rainfall areas in South Australia   and thos eugenii , which dPetrogale) as the name implies are wallabies whose primary habitat is rocky outcrops. They occur across the continent often in highly disjuct populations and currently 17 species are recognised , P. purpureicollis, P. rothschildi and P. xanthopus and of these, only P. purpureicollis has been examined for parasites in any systematic fashion   ranges from 10 to 21 with gastric nematode burdens ranging from 3100–12,450   while fomani see , which omani see . The Prohabitant  and is a0–12,450 , with coectively . In P. p is 6150 . Therefomilarity , with cor higher . Specieseicollis . These orsephone  are not ot clear .Table 3NP. penicillata complex are shared with P. purpureicollis in the arid zone  as well as Rugopharynx alpha are found only in rock wallabies inhabiting the arid zone  . Howevees race)  suggestiR. australis-R. macropodis in which distributions between arid and humid zones are evident, but for most helminth species adequate distribution data are not available. In addition, particularly in the case of the large kangaroos, distributions overlap at the margins of their ranges and the lie within a gradation of climate characters from humid coastal regions to drier inland regions with particular overlap in semi-arid regions.The overall conclusion that can be drawn from an analysis of the helminth communities in representatives of the macropodids is that while there are differences in the composition of communities between rain-forest dwellers and non-rain-forest dwellers, the differences between those inhabiting forests and open woodlands in the humid zone but extending into the semi-arid regions generally differ only in their species composition from those macropodids occurring almost exclusively in the arid zone. It is possible to highlight species pairs such as Amblyomma triguttatum, A. t. rosei extends into the arid zone  “camp” during the day under isolated trees on open plains. It feeds rapidly on resting kangaroos, returning to its subterranean environment to moult or breed  is ideally suited to surviving in arid environments.The argasid or ‘soft tick’ rid zone . It is for breed . Two forrobustus . This tiThus, while the differences between the internal helminth parasites of kangaroos inhabiting coastal/semi-arid environments are relatively subtle, there are more potentially more striking differences in their ectoparasites.6Vombatus ursinus, occurring in high rainfall areas of south-eastern Australia including Tasmania Vombatus eensland .Vombatiform marsupials were common in the ancient rainforests of central Australia  with theMacropostrongyloides, Phascolostrongylus and Oesophagosomoides which occur in the colon. Quantitative data are limited, but burdens of 1000–6000 O. stirtoni and 200 M. lasiorhini have been reported in L. latifrons  occurring in the bile ducts of the two species of wombats. Thus, the gastrointestinal helminth fauna of the two species of wombats is quite similar showing relatively few differences between humid and semi-arid environments. However, life cycle studies would be necessary to elucidate the ways in which species of nematodes have adapted to the semi-arid environments inhabited by L. latifrons.Data of helminth communities are available for only two of the extant species, but they allow a comparison between forest-adapted and arid adapted host species. The dominant gastro-intestinal helminths of wombats are the strongylid nematodes of the genera atifrons . Skerrat ursinus , the rem ursinus . The twoSarcoptes scabiei, which is found in both wombat species  three of which  are only found on this species of wombat. Echidnophaga eyrei is also found on V. ursinus and E. perilis is found on a variety of host species  have ever been examined for helminth parasites and the genera of trichostrongyloid nematodes found in them, Austrostrongylus and Nicollina  and the forest/arid zone -inhabiting genus (Pseudomys) both in terms of numbers of families and numbers of species encountered. Currently, it is not possible to distinguish between the ecological and phylogenetic factors potentially responsible for these differences, but the helminth communities in Pseudomys are quite depauparate when compared with the rain-forest inhabiting genera  the larva hatches from the ingested highly resistant egg (Zyzomys argurus is similarly depauparate, with dominance by species of Syphacia (The helminth fauna of Australian rodents remains relatively poorly studied , particud Uromys  allow corid zone . While Uustralia . The ranrid zone . Distribrid zone . The datg genera . The mostant egg  suggestiSyphacia  but studNotomys and in the case of Rattus, by the lack of studies of the sole arid-adapted species R. villosissimus.More general comments on the adaptation of rodent parasites to the Australian arid zone are limited by the almost total lack of studies of the species of Conclusions from studies on rodents need to be approached with caution due to the obvious deficiencies of comprehensive studies, but there are some parallels with the studies of macropodids in that there appears to be a significance difference in helminth faunas between those of rain-forest inhabitants and other rodents for which studies are available, with a more subtle difference between helminth communities of rodents in coastal open forests and those in the arid zone. More extensive studies are clearly needed to clarify these differences.9While the arid-adapted mammalian fauna of Australia clearly harbours extensive communities of both ectoparasites and helminths, the relative lack of documentation of the parasite fauna in the arid zone and the almost total lack of life history and biological studies of this fauna limits the observations that can be made concerning parasite adaptation. However, there are a number of relatively clear patterns. In both macropodids and rodents, the fauna present in rain-forest inhabiting host species is quite different from that found related genera and species inhabiting the open forests or shrublands of the coastal zones and the arid interior. The differences between helminth communities of macropodids, wombats and rodents in coastal, open forests or shrublands and those of the arid zone are less obvious and there are often differences at the parasite species level. Given the ecological history of the Australian continent with the gradual disappearance of rainforests and the increasing aridity in central Australia, these changes are probably not surprising and concord with conclusions from botanical studies which indicate that the flora of the central arid zone is recent in origin and is derived primarily from the surrounding semi-arid areas .Currently it is possible to identify differences in the helminth and arthropod fauna between the various climatic regions in and around the central Australian arid zone but identifying the biological adaptations of the parasites surviving in these environments must await studies of their biology which are currently almost entirely lacking.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Systemic inflammatory response syndrome (SIRS) reportedly has a low performance for distinguishing infection from non-infection. We explored the distribution of the patients diagnosed by SIRS (SIRS patients) or a quick sequential organ failure assessment (qSOFA) (qSOFA patients) and confirmed the performance of the both for predicting ultimate infection after hospital admission. We retrospectively analyzed the data from a multicenter prospective study. When emergency physicians suspected infection, SIRS or the qSOFA were applied. The area under the receiver operating characteristic curves (AUC) was used to assess the performance of the SIRS and qSOFA for predicting established infection. A total of 1,045 patients were eligible for this study. The SIRS patients accounted for 91.6% of qSOFA patients and they showed a higher rate of final infection than that of non-SIRS patients irrespective of the qSOFA diagnosis. The AUCs for predicting infection with SIRS and a qSOFA were 0.647 and 0.582, respectively. The SIRS significantly predicted an ultimate infection  in patients who met the SIRS and qSOFA simultaneously. In conclusion, the SIRS patients included almost all qSOFA patients. SIRS showed a better performance for predicting infection for qSOFA in those who met both definitions. Systematic reviews and meta-analyses in various settings, e.g. emergency departments, intensive-care units (ICUs), and general wards have consistently demonstrated a high sensitivity and low specificity with SIRS criteria but a low sensitivity and high specificity with the qSOFA score for predicting hospital mortality in patients suspected of or with an infection10. Herwanto et al.11 robustly confirmed these results presenting the area under the receiver operating characteristic (ROC) curve (AUC) and noted that neither score is perfect, each having its own limitations.Since the announcement of the third international consensus definitions for sepsis and septic shock (Sepsis-3), much debate has been had on the accuracy of the quick sequential organ failure assessment (qSOFA) score for predicting mortality due to sepsis compared with the systemic inflammatory response syndrome (SIRS) criteria3. No difference in the accuracy for diagnosing sepsis defined by the Sepsis-3 criteria has been reported between SIRS criteria and qSOFA scores10; however, another systematic review and meta-analysis reported the significantly superior performance of the SIRS criteria to the qSOFA score for diagnosing sepsis in patients outside the ICU12. One unresolved issue is the performance of the SIRS criteria and qSOFA score for predicting established infection as distinguished from noninfectious insults in patients with suspected infection. A previous report found that infectious patients who met the SIRS criteria included almost all of those who met qSOFA definition in the emergency department13. Another issue to be resolved is the degree of overlap between the patients who met the SIRS criteria (SIRS patients) and those who met qSOFA definition (qSOFA patients) in patients with suspected infection.One reasons the Sepsis-3 criteria were proposed was under the definition of SIRS, systemic inflammation due to infectious and non-infectious insults such as pancreatitis and trauma, it is difficult to differentiate sepsis from noninfectious insultsThe objectives of this study conducted in an emergency department were exploring the distribution of the patients with suspected infection diagnosed based on the SIRS criteria or qSOFA score and to confirm the performance of the SIRS criteria and qSOFA score for predicting an ultimate infection diagnosis after hospital admission as distinguished from noninfectious insults.This is a retrospective prognostic study used the data of the Emergency Room (ER) cohort from the prospective, multicenter study of the Japanese Association for Acute Medicine (JAAM) Sepsis Prognostication in Intensive Care Unit and Emergency Room (SPICE) study, comprising the SPICE-ER and SPICE-ICU cohort. The main study of the SPICE-ER cohort externally validated the accuracy of the SIRS criteria and qSOFA score for predicting mortality in patients suspected of having an infection in the emergency department. The JAAM SPICE-ER study used samples from 35 emergency departments in tertiary hospitals. The patient recruitment and data collection were conducted from December 2017 to February 2018 and the included patients were followed up to their discharge of the hospital. The JAAM SPICE-ER was registered in the University Hospital Medical Information Network Clinical Trial Registry (UMIN-CTR ID: UMIN000027258).This study was conducted in accordance with the amended Declaration of Helsinki, and was approved by the JAAM and the Ethics Committee of each hospital waiving written informed consent .>16 years old who (1) were suspected of having an infection by the emergency physicians and (2) had received any kind of antibiotics, had their body fluid cultured, or had imagining done for the detection of infection sites during their stay in the emergency department. Patients were excluded if they were transferred to another hospital without first being hospitalized at the participating hospital.The JAAM SPICE-ER study enrolled patients 14, Charlson comorbidity index15, lactate levels, and parameters for calculating SIRS criteria and qSOFA score were obtained. The SIRS criteria were defined according to the original consensus study (Sepsis-1)2 and the qSOFA score was based on the Sepsis-3 definition1. SIRS criteria >2 and qSOFA score >2 met the definition of SIRS and qSOFA, respectively. The suspected infection sites were classified into 12 regions, including the respiratory tract, urinary tract, abdomen, central nervous system, skin and soft tissue, bone and joint, wounds, intravascular catheter, endocardium, any kind of implant aside from an intravascular catheter, others, and unknown origin. The ultimately confirmed sites of infection after hospitalization were classified into the same categories and final diagnosis of infection or non-infection was also determined after admission to the hospital. The primary outcome of this study was an ultimate diagnosis of infection after admission.In addition to the baseline characteristics of the patients, the clinical frailty indexThe statistical parameters required for the original study sample size estimation were not available from previous studies, therefore, the original study employed an adaptive sample size estimation design.th–75th interquartile range and nominal variables are shown as the number (percentage). The chi-square test or Fisher’s exact test for nominal variables was used when required. The ROC curve was constructed, and the AUC was used to assess the predictive ability of an ultimate infection diagnosis. Missing values were used without manipulation. Differences with a two-tailed p value of <0.05 were considered statistically significant. The IBM SPSS 25.0 for MAC OSX software program  was used for the statistical analyses and calculations.Numeric variables are expressed as the median with the 25The flow diagram showing the study population as well as inclusions and exclusions is presented in Fig. Figure Table Figure According to the present study, the SIRS patients included almost all qSOFA patients, and the SIRS patients showed a higher percentage of an ultimately established diagnosis of infection than the non-SIRS patients irrespective of the qSOFA score. The SIRS criteria, especially in patients who met both the SIRS criteria and the qSOFA score, showed a significant AUC for predicting an ultimate infection diagnosis after admission to the hospital.11. However, information regarding an established diagnosis of infection, sepsis, and septic shock was lacking in that meta-analysis. The main reason for replacing the sepsis definition in 1992 (Sepsis-1)2 with Sepsis-33 was that SIRS criteria were extremely sensitive, leading to the misdiagnosis of non-infectious insults such as trauma, burns, pancreatitis, and ischemia-reperfusion events, as true infection16. However, in contrast to those previous findings, the present study showed a good predictive ability of the SIRS criteria for an ultimate diagnosis of infection.A systematic review and meta-analysis including a large patient population showed that the qSOFA score had greater ability than the SIRS criteria for predicting sepsis mortality and secondary outcomes such as organ dysfunction, ICU admission, ventilatory support, a prolonged ICU stay, and the 30-day outcome12. The results of present study and this meta-analysis are inevitable as the qSOFA score has been established and validated as a prognostic tool for hospital death in the patients with suspected infection17, while the SIRS criteria are used as a screening tool for severe sepsis which is defined as systemic inflammation with organ dysfunction according to Sepsis-12.In the current study, the AUC of the qSOFA score for predicting real infection was narrower than that of the SIRS criteria in patients with suspected infection. In addition, a non-significant AUC of the qSOFA score for predicting established infection was observed in patients who met both the SIRS criteria and qSOFA definitions. Not all patients with infection progress to sepsis. However, a systematic review and meta-analysis concluded that the SIRS criteria were significantly more accurate than the qSOFA score for diagnosing sepsis according to Sepsis-31. In the first large validation study of Sepsis-3 in patients suspected of having infection who presented to the emergency department, the patients without infection were excluded from the validation, and the conclusion was that the qSOFA score had a greater prognostic accuracy for hospital mortality than the SIRS criteria18. There may be some inconsistencies between the original paper and the validation study18. It is a time to become aware that the primary outcome of the study attempting to compare the SIRS criteria and qSOFA score is not the prediction of hospital mortality but the prediction of infection that progresses to sepsis or prediction of sepsis itself.Despite the above issues, the international consensus of Sepsis-3 used the qSOFA score as a screening tool for diagnosing sepsis, namely dysregulated host responses to infection associated with organ dysfunction (SOFA > 2)et al.13, who showed that the SIRS patients include almost all qSOFA patients among the infectious patients. The present and previous findings suggest that the SIRS criteria can replace the qSOFA score as a screening tool for sepsis in patients with suspected infection1. Alternatively, the combined application of those two tests for patients with suspected infection may improve the accuracy of both as screening and prognostic tools.Among patients with suspected infection, a significant portion (91.6%) of those who met the qSOFA definition were included in those who met the SIRS criteria. These results were consistent with those obtained by Henning 19. That study further showed that the NEWS was more accurate for detecting sepsis than the SIRS criteria (AUC of NEWS vs. SIRS criteria: 0.91 vs. 0.88) and recommended the NEWS as a screening tool for sepsis in the emergency department. However, screening of sepsis should be performed based on the pathophysiology of sepsis rather than using the simple warning score like the NEWS. Namely, SIRS, defined as systemic inflammatory responses to the infection would be good screening tool for sepsis, because the SIRS criteria are based on the sepsis pathophysiology as described in Sepsis-12.On comparing the SIRS criteria, qSOFA score, and the National Early Warning score (NEWS), the qSOFA score had the lowest sensitivity and was recognized as a poor tool for use in emergency department sepsis screeningThe strength of this study was our use of prospective data collected by the emergency physicians immediately after presentation to the emergency department. However, several limitations associated with the present study also warrant mention. The retrospective nature of the analyses may have limited the robustness of the study. The sample size was determined for the validation of hospital mortality predicted by the SIRS criteria and qSOFA score in the original study. Diagnostic data on non-infectious insults were lacking. The present study was a single national study conducted in a developed country in an emergency department setting, which may limit the generalizability of the obtained results. However, we believe that our study highlighted important discussion points for the future studies, supporting the further comparison of the SIRS criteria and qSOFA score.In the emergency department patients with suspected infection, the SIRS patients included almost all qSOFA patients and were associated with higher incidence of an ultimate infection diagnosis than non-SIRS patients irrespective of the qSOFA diagnosis. The SIRS criteria were significantly more accurate in predicting an established infection, especially in those who met both the SIRS criteria and the qSOFA definition. These results may suggest that the qSOFA score can be replaced with the SIRS criteria as a screening tool of infection likely to progress to sepsis. Alternatively, the combined application of both the SIRS criteria and qSOFA score in patients with suspected of having infection may improve the screening and prognostic accuracy of these factors for predicting infection and/or sepsis and a poor outcome.This study was approved by the JAAM and the Ethics Committee of each hospital waiving written informed consent .


The impact of nonlinear thermal radiations rotating with the augmentation of heat transfer flow of time-dependent single-walled carbon nanotubes is investigated. Nanofluid flow is induced by a shrinking sheet within the rotating system. The impact of viscous dissipation is taken into account. Nanofluid flow is assumed to be electrically conducting. Similarity transformations are applied to transform PDEs  into ODEs . Transformed equations are solved by the homotopy analysis method (HAM). The radiative source term is involved in the energy equation. For entropy generation, the second law of thermodynamics is applied. The Bejan number represents the current investigation of non-dimensional entropy generation due to heat transfer and fluid friction. The results obtained indicate that the thickness of the boundary layer decreases for greater values of the rotation parameter. Moreover, the unsteadiness parameter decreases the temperature profile and increases the velocity field. Skin friction and the Nusselt number are also physically and numerically analyzed. Applications of nanofluids in technology and science are increasing day by day, and they play an important role in various machinery and engineering applications such as detergents, microchip technology, transferences, micromechanical systems and biomedical applications. In light of these applications, researchers have applied modern techniques and have modified the base fluids by adding ultra-fine solid particles. A fast-growing field of research is micro channel cooling, floor heating and heat renewal systems in various industries, which have been flourishing in the current era. In comparison to base liquids, nanofluids have higher single-phase thermal conductivity and heat transfer coefficients.Khan  scrutini9 nm sized materials such as nanotubes, nanofibers, droplets, nanoparticles, etc. The solid phase and liquid phase create a two-phase system. Moreover, stable fluids have good writing and spreading properties on hard surfaces. Using nanofluids, the thermal conductivity of fluids can be enhanced .The modeled Equations (11)–(13) with boundary conditions from Equation (14), together with the conditions from Equations (23) and (27), are solved with HAM. The homotopy analysis method is applied due to its outstanding results in boundary layer equations. Several researchers ,48,49,50They have the following applicability:In this section, the physical outcome of dissimilar parameters of the modeled problems and their effects on The influence of the physical parameters Br. The higher Now, we analyze the impact of the parameters that perform a role in entropy generation and the Bejan number (Equations (23) and (27)). The influence of The unsteadiness parameter decreases the temperature profile and increases the velocity field.The thermal boundary layer thickness is reduced for larger values of the rotation rate parameter.The heat transfer rate rises for greater values of With increasing values of The performance of Entropy generation is increased with the increase of Velocity and temperature profiles decrease due to the increased unsteadiness parameter.Greater values of The exploration of nanoparticles preparations has introduced more deliberation in mechanical and industrial engineering owing to their probable use for increasing the continuous phase fluid thermal performance of cooling devices. A significant source of renewable energy is thermal radiation, which can be beneficial to govern overall population levels. In the present work, the second law of thermodynamics is applied in terms of the impact of nanoparticles on non-dimensional entropy for rotating flow with suggested thermal radiation. Mathematical modeling is established by modeling five different types of nanoparticles with the purpose of achieving an appropriate mechanism to enhance the thermal conductivity of continuous phase fluid. The following conclusions can be made:


The study was conducted in the raised bog Kusowo . Along a transect line crossing two open mires affected by forest succession we analysed tree age distribution. One of those mires had been drained in the past years and still retained some open ditches, while the other one was located far from the ditches. Every 10 meters along the transect line one tree was drilled at the root collar in order to determine its age. We also conducted phytosociological analyses and short-term water level measurements in the sample plots. We expected faster tree encroachment in the undisturbed part of the open mire. The results showed, that there were no significant differences in water table level and in soil moisture indicator values between the formerly drained and undisturbed open mire. There were also no statistically significant differences in tree encroachment between the disturbed and undisturbed mires. Location and the age distribution of the trees suggest that changes in the tree growth conditions cannot be directly explained by the general decreasing of water level in the bog, although periods following drainage works were associated with more numerous establishment of young trees, in the drained part of the bog as well as in the part not directly affected by drainage ditches. Picea abies, Downy birch Betula pubescens; however, a major role is usually played by Scots pine Pinus sylvestris. Scots pine is the most widespread tree species in the eastern Europe, inhabiting a wide range of habitats, from relatively poor and dry soils developed from post-glacial sand deposits to extremely wet habitat on the margins of peat bogs. It is also a light demanding tree species, and can reach very old age, especially when growing slowly in harsh environmental conditions [Sphagnum mosses dominated environment. Once the Scots pine gets established in peat bogs, it has been gradually changing the environmental conditions and vegetation structure in the close neighbourhood. Scots pine is capable of impeding peat accumulation in a significant way [Peat bogs are among the most important ecosystems for water retention , they arnditions . Pine ennditions –17. Somenditions . In natunditions , and thenditions , 20, 21.cant way . Howevercant way .Drainage breaks this natural cycle of tree establishment and tree dieback allows Scots pine to persist in open mires and eventually turn it into a pine bog forest. Intensified tree encroachment as a result of drainage was reported in numerous studies , 23–28. The aim of this study was to analyse the spatial dynamics of the system of open mires (*7110 Natura 2000 site) and bog woodlands (*91D02 Natura 2000 site). Because of the draining of the mire conducted in the past, the spatial relationship between these two communities had been probably changed in a substantial way.Our first hypothesis was that the tree encroachment onto open mires is related to the distance to the nearest ditch; we expected Scots pines to get established in higher numbers drained part of the peat bog, where the lowered water table should have produced conditions more conducive to tree growth and survival.Our second hypothesis was that the intensity of tree encroachment was greatest just after building the ditches, and then it has gradually slowed down. The ditches have not been properly maintained, and since the establishment of the reserve they were abandoned, and nowadays they are not visible in aerial photographs. Thus the role of drainage ditches in promoting tree establishment should have been more pronounced in the past, when their effect on water table level was probably much stronger than in recent times.P. sylvestris) from the edges towards the central, open mire. About two-third of the reserve is now covered with bog forests Vaccinio uliginosi Pinetum sylvestris and V. uliginosi-B. pubescentis, and one third is an open mire, mostly the Sphagnetum magellanici and the Eriophorum vaginatum-Sphagnum recurvum community. There are also small patches of beech forests on the mineral deposits on the margin of the reserve.The study was conducted on the Baltic bog located in the west Pomerania (north-western Poland), in the Kusowo Bog Nature Reserve  covering the area of 326 ha. This peat bog has been considered as one of the best preserved raised peat bogs in Poland. Research area comprises several mires gradually overgrown by the Scots pine  and another mire without any presence of the ditches confirmed by available cartographic materials . The lengths of transects in the disturbed mire and undisturbed mire amounted to 331 m and 277 m, respectively.Along the transect line every 10 m at least one nearest tree was selected for age determination. The height of each investigated tree was measured . In caseFor conducting the field work in the nature reserve we obtained a permit number WOPN.6205.55.2.2011.JS, issued on December 2, 2011 by the Director of the Regional Agency of Nature Conservation in Szczecin.On the basis of the phytosociological relevés we calculated the Ellenberg’s indicator values  for eachFrom the series of measurements of water table depth, we calculated the mean value and the range between the maximum and minimum water table depth as a measure of water conditions in that place. Using Spearman rank correlation, we determined the relationship between the Ellenberg’s soil moisture value F and the mean water table level for each sample plot ) test we compared the distributions of Ellenberg indicator values for sample plots located in the undisturbed mire (MU) with these located in the disturbed mire (MD) and in the whole area of the reserve, containing open mires, partly overgrown mires and pine swamp forests. Using the same method, we compared the distributions of mean values of water table depth and range of water table changes for sample plots located in the Undisturbed mire (MU) in the disturbed mire (MD) and in the entire Kosowo bog reserve. Age distributions of tree growing in the disturbed mire and in the undisturbed mire were compared using the Kolmogorov-Smirnov two sample test.Employing Kruskal–Wallis (one-way ANOVA on ranksSphagnetum magellanici (disturbed and undisturbed), two types of forest communities (Vaccinio uliginosi-Pinetum and Vaccinio uliginosi-Betuletum) and two type of transitional character, with disturbed/undisturbed Sphagnetum magellanici mires already invaded by pine trees. In our analyses we considered this variable as a random effect.For the purpose of investigation of the combined effect of different environmental factors on tree age and tree height we built a linear mixed model. In this model, we used independent quantitative factors expressed as weighted averages of the relevant Ellenberg’s indicator values as fixed effects. As comparing the forest versus open mire would yield very imprecise estimation of variance , we usedp-value level equal to 0.0011 in the first case and 0.018 in the second case. These results suggested statistically significant differences in the levels of variation between both mires.Water table level ranged from 0 to -45 cm; the average value was closest to the ground surface in case of the undisturbed mire, and slightly deeper and much more variable in the disturbed mire and in the whole area of the reserve . Similarp-value less than 0.00001.Calculating the unweighted Ellenberg indicator values for moisture (F) yielded consistently high values with little variation in the two open mires, while in the rest of the reserve there were some plots with moderate values of moisture indicators . The higp = 0.6691). Both measures of local wetness indicate no significant differences between the disturbed and undisturbed mires. The direct measurements using piezometers had been conducted in one year, so they can be affected by a specific weather pattern of a given year. However, the estimates based upon the species composition of the plant cover  are more stable, as the changes in mire vegetation are relatively slow.Analysis of the rank correlation between the average water table level and the Ellenberg’s indicator values for soil moisture (F) showed no significant correlation between these two variables , whilst trees on both mires displayed similar patterns in time of establishment. Up to 1860’s the rate of tree encroachment was low  as fixed effect and the plant community type as random effect . Howeverp-value < 0.00001) and soil nitrogen content  with significant difference of Vaccinio uliginosi-Betuletum plant community type in comparison to disturbed Sphagnetum magellanici as reference type of plant community, a variable which explains 55% of the variance of results between the outcomes. Similarly, the analysis of the relationship between tree age and other environmental factors yielded a significant difference of the undisturbed Sphagnetum magellanici vegetation SM2 type in comparison to the disturbed Sphagnetum magellanici SM1, explaining 26% of the total variance of the outcome Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Several studies have demonstrated that severe tricuspid regurgitation (TR) has a significant negative impact on morbidity and mortality. Nowadays, several therapeutic options to treat TR are available and patients at high surgical risk can also be treated with transcatheter procedures. For the management of patients with TR, an accurate assessment of the tricuspid valve and its surrounding structures is therefore of crucial importance and has gained significant interest in the medical community. Different imaging modalities can provide detailed information on the tricuspid valve apparatus, right ventricle, right atrium, and coronary circulation which are fundamental to define the timing and anatomic suitability of surgical and percutaneous procedures. The present review illustrates the role of 2D and 3D echocardiography, cardiac magnetic resonance, and multidetector row computed tomography for the assessment of the tricuspid valve and right heart with a particular focus on the data needed for planning and guiding interventional procedures. The tricuspid valve (TV) apparatus is a complex structure consisting of three leaflets inserted in the tricuspid annulus (TA) and connected to the papillary muscles of the right ventricle (RV) through the chordae tendinae . The funCurrent American and European guidelines recommend TV interventions (preferably TV repair) at the time of left-sided valve surgery in case of severe TR (class I) or in the presence of TA dilation regardless of TR severity (class IIa) , 10. On The TV is the atrioventricular valve located between the RA and RV  with a mThe identification of the potential mechanisms underlying TR represents the first step in the evaluation of patients with TR. The causes of TR can be grouped into two main categories, primary TR and secondary TR  Figure . PrimaryTransthoracic two-dimensional (2D) echocardiography is the pivotal imaging modality to evaluate the TV apparatus, RA and RV due to its wide availability. Echocardiography provides fundamental information regarding the anatomy and specific lesions of the leaflets and whole valvular apparatus, including surrounding structures which are very important to identify the etiology of TR . Conside2 is indicative of TA dilatation. In secondary TR, the TA dilates more posteriorly and its shape becomes more circular as TR becomes more severe. Accordingly, it had been demonstrated that 2D echocardiography systematically underestimates the TA diameter compared to a 3D assessment  is characterized by high spatial resolution which makes this imaging modality ideal to assess the TA dimensions and the relationship of the TA with the RCA which are fundamental to plan interventional procedures on the TA  . The quaCardiac magnetic resonance (CMR) is the gold standard imaging modality to evaluate RV size and systolic function without the use of contrast media . HoweverEchocardiography represents the mainstay imaging modality to grade TR severity . AccordiThe qualitative parameters of TR severity are not based on mathematical formulas but mainly on the subjective assessment of the physician and therefore are largely dependent on experience and come with limitations. A large color Doppler flow convergence in the ventricular side of the TV throughout the systole suggests severe TR. However, this parameter is highly dependent on the settings of the machine, loading conditions and can underestimate TR severity in the presence of eccentric jets. Moreover, the density, timing and shape of the continuous wave Doppler jet of TR can be informative on TR severity. A dense, holosystolic, with an early peak TR jet is suggestive of severe TR.2 indicates severe TR and the same applies to a ratio between the regurgitant jet area and RA area > 33%. The vena contracta (VC) width is another semi-quantitative parameter of TR severity and represents the diameter of the narrowest portion of the regurgitant jet immediately downstream of the regurgitant orifice. A VC width ≥ 7 mm is consistent with severe TR. A proximal isovelocity surface area (PISA) radius ≥ 9 mm  is also indicative of severe TR. The presence of systolic reversal flow in the hepatic vein (sampled with pulse wave Doppler) represents a specific but not sensitive parameter of severe TR because it is largely affected by the direction of the jet and by the presence of atrial fibrillation. Finally, the evaluation of the tricuspid inflow pattern with the pulsed-wave Doppler can indicate the severity of TR. A prominent E wave (>1.0 m/s) is usually present in patients with severe TR; nevertheless, the tricuspid inflow pattern is highly affected by the cardiac rhythm and should not be taken into account as an index of TR severity in patients with atrial fibrillation.Semi-quantitative parameters of TR severity provide a more detailed picture on TR severity compared to a qualitative assessment. A color Doppler TR jet area > 10 cm2 and a regurgitant volume ≥ 45 ml/beat are suggested by the guidelines to identify severe TR  and regurgitant volume based on the PISA method. Although, EROA can be underestimated in the presence of an elliptic orifice, recent studies have shown an important relation of this parameter with prognosis in patients with significant TR . An EROAevere TR .2) and torrential TR (VC width ≥ 7 mm and EROA ≥ 80 mm2) showed to be useful to predict patient outcomes in patients with significant secondary TR , the systolic excursion velocity of the lateral portion of the TA (S') and RV fractional area change (FAC) are the most widely used standard 2D echocardiographic parameters of RV systolic function . TAPSE iAll the conventional echocardiographic parameters are highly affected by loading conditions and may not be representative of RV contractility. Speckle-tracking echocardiography (STE) is angle independent and the STE-derived global and free-wall longitudinal strain are less load dependent parameters of RV systolic function . RV globThe complex RV geometry and systolic function can be better assessed with 3D imaging techniques. Although still challenging by suboptimal quality of the acoustic window, 3D echocardiography can be useful for an accurate assessment of RV volumes and to calculate RV ejection fraction . An exceDifferent surgical and percutaneous options are currently available for the treatment of TR and, similarly to other valvular heart disease , multimoIn patients undergoing cardiac surgery for other indications or not at high surgical risk, surgery represents a valuable option to treat TR. Overall, surgical TV repair should be preferred over TV replacement because, when feasible, it is associated with less complications and better outcomes . The aimIn patients at high or prohibitive surgical risk or without the need of other cardiac surgeries, a transcatheter procedure to treat TR can be considered. Different options exist and again the choice should be based on the pre-procedural assessment and identification of the mechanism of TR, mainly using echocardiography. In patients where the dilation of the TA is the main mechanism causing TR, a transcatheter direct annuloplasty represents a valuable option and three systems are currently available: the Trialign system, the TriCinch device, and the Cardioband system. The Trialign is a suture based TV direct annuloplasty system that reduces the TA diameter through tissue plication . From a The Cardioband system is the percutaneous equivalent of the surgical undersized annuloplasty. This system consists of an adjustable, sutureless annuloplasty band of polyester through which anchors are inserted . The sysAnother percutaneous option to repair the TV is represented by the devices that can restore the TV leaflet coaptation. The Triclip system is an adaptation of the Mitraclip system to the TV. Both the Mitraclip and the Triclip systems can be used to achieve a percutaneous edge-to-edge repair of the TV and are useful to treat either primary or secondary TR . Two sizTranscatheter TV replacement represents a valuable option in the case of failing TV annuloplasty or biological TV prosthesis. Prostheses normally applied in the aortic position have been successfully used for valve-in-ring or valve-in-valve procedures on failing TV annuloplasty or biological TV prosthesis . A meticFinally, transcatheter valves can be implanted in the superior and/or inferior caval veins to reduce the backflow of blood from the incompetent TV to the caval veins and reduce symptoms and signs of venous congestion. The implantation of balloon-expandable valves requires pre-stenting of the inferior vena cava to downsize the landing zone and ensure safe anchoring of the transcatheter valve . On the Similar to transcatheter procedures on heart valves other than the TV, intraprocedural guidance of percutaneous procedures on the TV relies on multimodality imaging . 3D tranTransthoracic 2D/3D echocardiography is the main imaging modality used for the follow-up of patients after surgical or percutaneous procedures on the TV. Several information should be assessed and recorded. First, it is very important to assess residual TR before discharging the patient as it may differ from the evaluation performed in the immediate post-procedural phase in the operating theater where the patient might have been under general anesthesia, invasive ventilation or sedation with different RV loading conditions. Qualitative, semi-quantitative and, most importantly, quantitative parameters of TR severity should be recorded  to allowThe accumulating evidence on the negative prognostic impact of TR and the development of effective transcatheter procedures to treat also patients with multiple comorbidities and at high or prohibitive surgical risk have increased the interest on the imaging of the right heart and TV. Multimodality imaging plays a key role to assess TR severity, TA dimensions, RV and RA remodeling, define the etiology of TR, choose the timing and the best therapeutic option, guide the procedure, prevent complications and follow-up patients with significant TR after interventions.FF wrote the first draft of the manuscript and prepared the figures and adjusted it according to the comments and suggestions of the co-authors. KH helped in preparing the figures and critically revised the manuscript. JB and VD critically revised the manuscript. NA helped in structuring the manuscript, preparing the figures, and critically revised the manuscript. All authors contributed to the article and approved the submitted version.The Department of Cardiology of the Leiden University Medical Center received research grants from Abbott Vascular, Bayer, Bioventrix, Medtronic, Biotronik, Boston Scientific, GE Healthcare, Ionis, and Edwards Lifesciences. JB received speaking fees from Abbott Vascular. VD received speaker fees from Abbott Vascular, Medtronic, Edwards Lifesciences, Novartis, MSD, and GE Healthcare. NA received speaker fees from Abbott Vascular and GE Healthcare. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In the summer semester 2020, the module "People in different stages of life" in the Bachelor program "Interprofessional Health Care, B.Sc." had to be adapted to online teaching. The module exam, originally planned as an oral presentation, was presented by the students in interprofessional tandems as a video presentation using case studies. Based on cognitive and social constructivism, all students reflected on these video presentations using the "Think-Pair-Share” method. Similar to regular inverted classroom methods, knowledge transfer through the video presentations was asynchronous and cognitively constructive; accompanying discussion questions of the respective speakers were answered in writing by the fellow students (Think). The students met independently online in small groups on a regular basis to discuss the respective presentations and questions based on personal and professional experiences . In open online debriefings with the lecturers, the speakers and all interested students, relevant aspects were taken up and discussed again (Share). First experiences showed that the students enjoyed the production of the video presentations and that many of them voluntarily participated in the discussion rounds, in which aspects of health care beyond the presentations were discussed. Considering the experiences made, continuing online teaching in this format may be worthwhile for both lecturers and students. Learning with digital media needs to be embedded in social interaction , 2], si, si2], sBy switching to sole online teaching, the 2-semester module "People in different stages of life" of the Bachelor program "Interprofessional Health Care, B.Sc." was also adapted.The challenge was to enable independent and collective online learning in a way that supported all students in cognitive and social knowledge construction. In the online format, the presentation was retained as a form of examination and implemented as a video presentation. The production of learning videos enables the independent construction of knowledge since content must be understood and didactically prepared . For refth semester (winter) providing students with theoretical basic knowledge about health and disease aspects in different stages of life. In the following summer semester, the students usually prepare a presentation in an interprofessional tandem, analysing a case study using a stage theory model , [, [th semry model , identifth semester  received sample videos and a written summary with information on video production at the beginning of the summer semester via an e-learning platform (Moodle); they evaluated the videos and derived criteria for effective videos in individual work. The submitted criteria were summarized by the lecturer in a document and made available to all students via Moodle, based on the constructivist approach.After the winter semester had taken place regularly, the 16 students in the 8The students (presenters) created video presentations with concluding discussion questions in interprofessional tandems following the regular requirements of the assignment. A maximum of 2 video presentations were made available to the students via Moodle on 5 fixed dates and were reflected upon and discussed in 14-day cycles using the "Think-Pair-Share” method . The written reflections showed that the students dealt intensively with the case studies and the module content in terms of cognitive knowledge construction (Think). The small group meetings (Pair) promoted independent learning and gave freedom of planning. At least 60% of the students took part in each of the 5 presentation meetings (Share). Topics that went beyond the presentation were discussed, expertise and perspectives were exchanged and social knowledge construction was achieved. The individual feedback of the lecturers, which often provided food for thought for the discussion, was experienced positively by the students as appreciation of their own workload, but was rarely taken up by them in the presentation meeting.The online application of the "Think-Pair-Share" method has been successful. Video presentations can be retained as an exam format. The production and reception of videos as a substitute for live presentations allows for an individual organisation of learning time and an experience-based occupation with the topic. Structured reflection and discussion enable collaborative and interprofessional learning.The presentation meetings should preferably be conducted face-to-face to foster blended learning, since online conferences allow less intensive interaction.For the feedback on the individual reflections, peer feedback could be useful in the context of Think-Pair-Share to promote further social knowledge construction. All in all, a clear formulation of the work assignment for the presentations and discussion groups is essential.The authors declare that they have no competing interests.


Local Positioning Systems are collecting high research interest over the last few years. Its accurate application in high-demanded difficult scenarios has revealed its stability and robustness for autonomous navigation. In this paper, we develop a new sensor deployment methodology to guarantee the system availability in case of a sensor failure of a five-node Time Difference of Arrival (TDOA) localization method. We solve the ambiguity of two possible solutions in the four-sensor TDOA problem in each combination of four nodes of the system by maximizing the distance between the two possible solutions in every target possible location. In addition, we perform a Genetic Algorithm Optimization in order to find an optimized node location with a trade-off between the system behavior under failure and its normal operating condition by means of the Cramer Rao Lower Bound derivation in each possible target location. Results show that the optimization considering sensor failure enhances the average values of the convergence region size and the location accuracy by 31% and 22%, respectively, in case of some malfunction sensors regarding to the non-failure optimization, only suffering a reduction in accuracy of less than 5% under normal operating conditions. Autonomous navigation has meant a challenge for scientific development over the last few years. The high accuracy required has entailed the interest in Local Positioning Systems (LPS) where the positioning signal paths are reduced between targets and architecture sensors. This fact significantly reduces noise and uncertainties by minimizing the global architecture errors with respect to Global Navigation Satellite Systems (GNSS). GNSS provide global coverage but the distortion of their signals in their travel affects the stability and the accuracy of the localization over time. In addition, GNSS navigation is denied in indoor environments, where Automatic Ground Vehicles (AGVs) mostly operate, as signals deteriorate crossing large buildings. This causes Non-Line-of-Sight (NLOS) connections between satellites and targets which makes position determination impractical. The application of also GNSS has limitations in outdoor environments such as low-altitude flights in Unmanned Aerial Vehicles (UAVs) due to the higher uncertainty in the vertical coordinate of the global systems. It is a consequence of the similar altitude of the satellites in their constellations.These reasons have promoted this new localization concept based on LPS especially for high accuracy automated navigation ,2. LPS rAmong these systems, the most extended are time-based models due to their reliability, stability, robustness and easy-to-implement hardware architectures. Time-based positioning has two main systems that differ in time measurements computed: Time of Arrival (TOA)  and TimeTOA systems measure the total time of flight of a positioning signal from an emitter to a receiver. It requires the synchronization of the clocks of all the system elements (i.e. targets and sensors). This leads to the generation of a sphere of possible locations in the 3-D space for each received signal in a different architecture sensor. The intersection of spheres determines the target location. Mathematical standards show that the unequivocal target location is achieved in TOA systems with at least four sensors.n-1) independent equations can be processed from n different sensors [TDOA systems compute the relative time between the reception of the positioning signal in two different architecture sensors. The synchronization of these systems is optional considering asynchronous TDOA architectures in which the time differences are computed in a single clock of a coordinator sensor  and sync sensors . The reqHowever, the intersection of three different spheres -3 architecture sensors- in TOA systems and three different hyperboloids -4 architecture sensors- in TDOA systems leads to two different potential solutions. Nevertheless, these solutions are not able to be discarded from a mathematical point of view.In one of our previous works , we haveThe sensor distribution also has relation with the global accuracy of the LPS. Traditionally, the Position Dilution of Precision (PDOP) has been used to determine the achievable accuracy of time-based positioning systems in GNSS  by consiThis fact promotes the use of Cramer Rao Lower Bound (CRLB) ,18 derivHowever, any of the approaches presented considers a possible sensor failure during the node distribution optimization addressed. This means that in these sensor deployments a sensor fault will cause the unavailability of TOA architectures with 4 sensors and TDOA architectures with 5 sensors. However, our finding in  has deteIn this paper, we propose for the first time a GA optimization for the 3D node deployment in a TDOA system with five architecture sensors with failure consideration, maximizing the performance during regular operation and in any possible sensor malfunction see . For thaThe remainder of the paper is organized as follows: the algorithm for the target unequivocal location determination is presented in Relative time measurements in TDOA systems lead to hyperboloid equations of possible target locations. These equations are non-linear so numerical methods are required to solve the intersection of the hyperboloids. The algorithms used have been classified in two main categories: closed-form algorithms and iterative methods.Closed-form algorithms ,29 proviThe position calculation with four architecture sensors in TDOA systems provides two possible ambiguous target localizations. The achievement of an unequivocal position cannot be determined according to mathematical standards. As a consequence, the position determination by means of iterative methods provides a unique solution that it might not match with the real target location. Nevertheless, we have shown in  that theThis finding enables LPS architectures of 5 sensors -minimum number of sensors to supply unequivocal target location- to provide stable and accurate service in case of sensor failure or temporal unavailability of one of the architecture nodes.E) to sensors i and j, c is the speed of the radioelectric waves, Taylor-Based algorithms in TDOA systems are linearizations of the equation of the time difference of arrival:i and j architecture sensors particularized in the initial iteration point.Taylor approximation truncated on first order is applied in Equation (1) to linearize the equation from an initial iteration point The application of this process to sensors ution in  generateCRLB is an unbiased estimator of the lowest variance of a parameter. Its usage in the localization field is widespread ,32,33 sii and j and It characterizes the WGN present in the time measurements of the time-based positioning systems. The uncertainties introduced in the measurements depend on the distance traveled by the positioning signal from the emitter to the architecture sensors in a heteroscedastic noise consideration. Recent studies  developeon model  obtaininThe inverse of the Fisher Information Matrix  are provided in The benefits of the consideration of the sensor failure in the architecture design have been shown through the differences in accuracy and convergence from the In The results of these tables reveal that the optimization carried out in Case I not only minimizes the CRLB (i.e. maximum achievable accuracy based on the conditions of operation) when only 4 sensors are accessible, it also maximizes the region where the Taylor-based positioning algorithm is able to operate .Optimizations with failure-consideration (Case I) increase the radius of convergence by 30.9 % in failure conditions while they also experience a boost of 8.5% in this confidence interval in the normal operating condition of five sensors availability. This is due to the convergence radius maximization in the failure-consideration optimization which is not considered in conventional sensor deployment methodologies. This shows that an increase in this confidence interval in the distributions of four sensors has also a direct effect in the convergence radius of the five-sensor normal operating distribution of the failure-consideration optimization. The beauty of this combined multi-objective optimization is that the accuracy of the four-sensor combinations in failure conditions has been increased by 22% while the accuracy of the normal operating five sensor distribution (Case I) has been reduced by less than 5% with regards to conventional node deployments (Case II) that only consider the five-sensor optimization. Furthermore, the achievement of higher values of the convergence radius in the failure-consideration optimization enhances availability and security in failure conditions by solving the ambiguity of two valid mathematical solutions and by increasing the confidence interval of applying Taylor-Based positioning algorithms in normal operating conditions with regards to conventional node deployment methodologies. This new optimization procedure considering sensor failures does guarantee the robustness of the positioning system in complex conditions of operations, and the design of architectures considering these situations.The location of sensors in LPS has been an active topic of research over the last few years ,22,23,24Nevertheless, in actual implementations of the LPS, some sensors are possibly denied for positioning due to the presence of obstacles that disturb signals introducing adverse effects such as multipath or signal deterioration. Furthermore, a possible sensor malfunctioning introducing noise in the measurements must be considered. These facts have not been studied in previous sensor distribution optimizations. In this work, we propose for the first time in the authors’ best knowledge a node deployment methodology that enhances position determination in case of a sensor failure. Additionally, we apply this process to the more restrictive TDOA system to unequivocally determine target location, i.e. five-sensor TDOA deployments. This leads to a sensor-failure configuration in which we first need to solve the position ambiguity determination in systems with only four nodes according to the finding that we proposed in .For this purpose, we performed a multi-objective optimization in a defined 3D irregular scenario in order to extrapolate the results to normal LPS applications. This optimization reduces the CRLB while it is also maximizing the radius of convergence of the Taylor-Based algorithm that we use for the target location determination. Results show the beauty and importance of this new technique as it is able to enhance the system behavior in failure conditions with regards to only nominal optimizations. This is particularly remarkable since conventional optimization approaches are only focused in nominal operating conditions of LPS and they can suffer from temporal unavailability that can motivate important drawbacks in autonomous navigation.Local Positioning Systems have emerged over the last few years for high-demanded accurate applications. Among them, time-based positioning architectures become predominant for its robustness, stability and trade-off between accuracy and complexity.In this paper, we propose a method to guarantee system availability under sensor failure. This is a key factor for the real operation of LPS as a consequence of the possible ineffective link between target and sensors in complex environments and possible sensor malfunctioning.In order to simulate an actual operation environment, we have defined a 3D irregular scenario consisting of a five-sensor deployment of a TDOA architecture. This configuration validates the methodology proposed for terrestrial and aerial applications in indoor and outdoor environments. In TDOA architectures, an unequivocal target location can be determined with a minimum of five sensors according to mathematical standards. However, we have proved that the ambiguity in the position determination with four sensors can be solved by the used of Taylor-Based positioning algorithms in a convergence region around the true target location which, in practice, corresponds with the maximization of the two possible solutions distance. The achievement of this disambiguation can be obtained through an optimized sensor distribution. The node deployment must also minimize the time measurement uncertainties which are characterized by means of the CRLB. For this reason, we implement a multi-objective optimization for the combined maximization of the accuracy and convergence under each possible sensor failure condition. In addition, the optimization needs to guarantee the reduction of the uncertainties for the nominal performance with five sensors.Results show that the proposed method can attain both accuracy and convergence requirements under every possible sensor failure condition. The global optimization with five sensors without sensor failure consideration overcomes the five-sensor deployment optimization with failure consideration in terms of medium accuracy during nominal operation by less than 5%. In contrast, in circumstances where some of the sensors are not available and only 4 sensors can be applied in the target position calculation, the optimization considering sensor failure increases the average values of convergence region size and accuracy by 30.9% and 22% respectively, regarding the non-failure optimization. These results show the importance of considering the anomaly cases of sensor failure during the LPS node distribution optimization in order to guarantee availability and operation quality in high-demanding accuracy applications.


Pharmacogenomics is one of the emerging approaches to precision medicine, tailoring drug selection and dosing to the patient’s genetic features. In recent years, several pharmacogenetic guidelines have been published by international scientific consortia, but the uptake in clinical practice is still poor. Many coordinated international efforts are ongoing in order to overcome the existing barriers to pharmacogenomic implementation. On the other hand, existing validated pharmacogenomic markers can explain only a minor part of the observed clinical variability in the therapeutic outcome. New investigational approaches are warranted, including the study of the pharmacogenomic role of the immune system genetics and of previously neglected rare genetic variants, reported to account for a large part of the inter-individual variability in drug metabolism. In this Special Issue, we collected a series of articles covering many aspects of pharmacogenomics. These include clinical implementation of pharmacogenomics in clinical practice, development of tools or infrastractures to support this process, research of new pharmacogenomics markers to increase drug efficacy and safety, and the impact of rare genetic variants in pharmacogenomics. Over the last twenty years, the study of human genetics has been fueled by cutting-edge sequencing technologies leading to a deeper understanding of the relationship between genetic variation and human health . The stugkb.org) . Howevergkb.org) . In thisSLC22A2 and ERCC2. Quite interestingly, they aim to define whether different clinical definitions of nephrotoxicity (adjusted-AKI or CTCAE-AKI designation) could have contributed to previous inconsistent results on the predictive role of the analyzed variants. They report that the association with the polymorphisms was only significant when considering the nephrotoxicity definition according to CTCAE v4.03. This paper raises the important issue of the definitions of clinically relevant outcomes in pharmacogenomics, which may have hindered the generation of solid and reproducible data among various studies in the field. More generally, heterogeneity in ethnicity, demographic characteristics and treatment modalities (dose or co-treatment) could affect comparability among studies. Yanqui Xu and colleagues [CYP2C9 (three variants) and VKORC1 (four variants) and warfarin anticoagulant effects, in a cohort of unrelated Jordanian-Arab patients with cardiovascular disease. Warfarin response was evaluated in terms of the achievement of a coagulation level in the therapeutic range during therapy and of the drug dose required by the patient. Variants of both genes were associated with warfarin effects and dose requirement. Interestingly, the haplotype derived by the combination of the variants of each gene were also associated with the effects of warfarin, confirming the relevance of the multilocus CYP2C9/VKORC1 genotype to improving warfarin therapy for Arab patients also. Lucafò and colleagues [TPMT, but also in two highly polymorphic glutathione transferase enzymes, in particular the GST-A1 and GST-M1 isoforms. Interestingly, all variants affected azathioprine efficacy in this cohort. In particular, TPMT polymorphisms, associated with reduced enzymatic activity, determined improved response to azathioprine, due to reduced inactivation of the drug. On the other hand, variants determining reduced activity of GST-A1 or GST-M1 determined reduced azathioprine efficacy, likely because of a lower drug activation. The effect on azathioprine metabolite concentration and dose was confirmed for GST-M1 and TPMT. Bise and colleagues [Six papers report original results on the discovery of new genetic markers of the outcome of a pharmacological treatment in terms of either efficacy or toxicity. Two papers focus on the pharmacogenomics of platinum derivatives. Dugo and colleagues  report tlleagues  describelleagues  evaluatelleagues  evaluateDPYD compound heterozygosity for two of the four DPYD genetic polymorphisms with a validated effect on fluoropyrimidines safety. The most difficult task in these cases is the phasing of the genotypes in order to obtain a proper translation of genotype to phenotype. Since currently available phasing strategies are difficult to translate into a diagnostic routine, the authors point out the necessity in these sporadic cases of performing DPD phenotyping based on the measurement of DPD activity, in order to define the real enzymatic capacity of each individual. The paper by Roncato et al. [Three papers report the results of research work aimed at investigating how to improve pharmacogenomic implementation in clinical practice. The work of Lunenburg and colleagues  approacho et al.  describeo et al.  investigCEP72 rs924607 TT genotype and its association with vincristine induced neuropathy. The authors underline that while a significant amount of data has been generated using high-throughput technologies, the clinical implementation of these findings is still limited. To increase clinical implementation of this outstanding research, the authors discuss the relevance of data analysis and of designing prediction models using bioinformatics, machine learning algorithms and artificial intelligence.This special issue also includes two outstanding literature reviews. Davila-Fajardo’s  revisionIn conclusion, the studies collected in this volume underline the potential of innovative molecular approaches, including multilocus genotyping, sequencing of rare variants and epigenetic features, in identifying genetic determinants of interindividual variability in the effects of drugs in several important clinical settings, including chemotherapy of breast cancer and leukemia and anticoagulant therapy for cardiovascular diseases. The integration of multiple layers of pharmacological information, including variation in gene expression and function of drug targets, pharmacokinetic profiles, also obtained through innovative statistical and bioinformatic approaches, holds the potential of explaining the predictable sources of interpatient variability in drug effects, which properly implemented will bring to precision therapy.