Removals of COD and NH4+-N were not affected but total nitrogen (TN) removal decreased. IBP and NPX had the high removal efficiencies (79.96% to 85.64%), whereas DCF was more persistent (57.24% to 64.12%). In addition, the decreased removals of TN remained the same under the three conditions (p > 0.05). The results of oxidizing enzyme activities, live cell percentages and extracellular polymeric substances (EPS) indicated that NSAIDs damaged the cell walls or microorganisms and the mixtures of the three NSAIDs increased the toxicity. The increased Shannon-Wiener diversity index suggested that bacterial diversity was increased with the addition of selected NSAIDs. Bacterial ribosomal RNA small subunit (16S) gene sequencing results indicated that Actinobacteria and Bacteroidetes were enriched, while Micropruina and Nakamurella decreased with the addition of NSAIDs. The enrichment of Actinobacteria and Bacteroidetes indicated that both of them might have the ability to degrade NSAIDs and thereby could adapt well with the presence of NSAIDs.This study covers three widely detected non-steroidal anti-inflammatory pharmaceuticals (NSAIDs), diclofenac (DCF), ibuprofen (IBP) and naproxen (NPX), as NSAIDs pollutants. The objective is to evaluate the impact of NSAIDs at their environmental concentrations on microbial community assembly and activity. The exposure experiments were conducted under three conditions (5 μg L Among them, diclofenac (DCF), ibuprofen (IBP) and naproxen (NPX) are frequently detected in the environment as trace emerging contaminants . DCF has-1 . IBP usu-1 . NPX is -1 . The gro-1 . In the in WWTPs –8. It wain WWTPs ,10.The fate of NSAIDs in WWTPs would be affected by various parameters . During wastewater treatment processes, NSAIDs would be transformed by abiotic processes  and biotic transformation/degradation . Tixier 4+-N removals were not affected by 5 μg L-1 of antibiotics but decreased significantly with the presence of higher concentration antibiotics (10 mg L-1). However, few researches have addressed the impact of NSAIDs on reactor performances.Most pharmaceuticals are released into WWTPs without specific treatment and WWTPs are not designed to remove pharmaceuticals. Currently, the effect of pharmaceuticals  on WWTP performance or the efficiency of plans for their removal has been extensively researched , 14, 15.-1) on biofilm communities and found that 100 μg L-1 DCF had significant effects on bacterial community compared to the control. Meanwhile, the use of carbon sources was significantly depressed (p < 0.05) with the presence of 100 μg L-1 DCF. Therefore, it is reasonable to infer that the shifts in microbial community might be detrimental to WWTP performance, such as COD removal rate.In most instances, municipal WWTPs use biological wastewater treatment processes to remove nitrogen, phosphorus and organic pollutants where microbial components of activated sludge drive the key processes. The existence and activity of microorganisms that can biodegrade NSAIDs play the most important role in the fate of NSAIDs in wastewater than their inherent physic-chemical properties and environmental factors . LawrencThe bacterial population is made up of macromolecules extracellular polymeric substances (EPS). Delgado et al.  reported4+-N and TN were measured regularly during operation time. The microbial activity and community in activated sludge were observed at steady state. The objectives of this study were to: (1) learn more information about the overall reactor performance with additions of selected NSAIDs, (2) investigate changes of microbial activity in sludge reflected by extracellular polymeric substances (EPS) and oxidizing enzyme activities, and (3) determine the shifts and diversity of the microbial community in activated sludge to selected NSAIDs. The present investigation contributes to the further understanding of the emerging contamination effect on the wastewater treatment process.This study operated lab-scale SBRs for 130 d to culture activated sludge with selected NSAIDs at environmental concentration. COD, NH-1) were prepared in methanol and stored under refrigeration at 4°C.DCF, IBP and NPX  were obtained from Sigma Aldrich (Steinheim Germany). Methanol, acetic acid and acetone  were purchased from Merck . Milli-Q water produced from a Millipore purification system  was used throughout except for synthetic wastewater. Other chemicals  were supplied by Nanjing Chemical Reagent Factory, China. Oasis hydrophilic-lipophilic balance (HLB) solid phase extraction (SPE) cartridges  were obtained from Waters . Individual analyte stock solutions  and at a hydraulic retention time of 10 h. The solid retention time (SRT) was set to 20 d by a daily manual purge. The reactors were continuously conducted with a 12 h cycle containing 30 min feeding, 600 min aeration, 60 min settling and 30 min decanting. The initial pH was controlled at 7.5±0.5 by using NaHCO-1. The initial concentration of COD, NH4+–N and total phosphorus (TP) in synthetic wastewater were 300±12, 20±1 and 3.5±0.5 mg L-1, respectively. One liter of synthetic wastewater also contained 12 mg of CaCl2·2H2O, 35 mg of MgSO4·7H2O and 0.3 mL of a trace nutrient solution. The trace nutrient solution was described by [-1 stock solutions which were diluted by 4 L of synthetic wastewater and finally maintained with the influent pharmaceutical concentration of 5 μg L-1. R0 was the control without pharmaceuticals and R1–R3 were set in different mixtures of selected NSAIDs added into the synthetic wastewater during the feeding period  levels were 3.5±0.2 g Lribed by . Selecteg period . After oAll enzymes were extracted from activated sludge during the stable stage in triplicate. The activities of superoxide dismutase (SOD) and succinate dehydrogenase (SDH) were evaluated by corresponding detection kits obtained from the Nanjing Bioengineering Institute (China). The catalog numbers for SOD and SDH are A001-3 and A022, respectively. All enzyme activities were normalized by total protein concentration. This study used the Micro BCA Protein Assay Kit obtained from Nanjing Bioengineering Institute to the distribution of proteins (PN) (China).Extracellular polymeric substances (EPS) are extracted from activated sludge . In mostLive and dead cell distributions in activated sludge after pharmaceuticals exposure was investigated with epifluorescence microscopy. This study used the LIVE/DEAD BacLight kit , which consists of propidium iodide (PI) and SYTO9. Green fluorescing SYTO9 was used for assessing the live cells, whereas red fluorescing PI was used to assess the dead cells. Twenty random fields were chosen and observed, and the rate of live/dead cells in activated sludge was calculated by quantifying the area of each image with the image processing software Image J . The final result of live/dead cells was assessed by the Green area/(Green area + Red area).4+–N, TN and MLSS were measured by Standard Methods for the Examination of Water and Wastewater [COD, NHstewater . pH and For evaluating the concentration of DCF, IBP and NPX, influent and effluent samples were collected from each reactor and filtered through a 0.22 um pore-size filter . Before determining the NSAIDs concentrations, the pH of each sample was adjusted to 2 with 2 M HCl. Pharmaceuticals were pretreated by solid phase extraction (SPE) and the detailed method was carried out according to . The finp < 0.05). Statistical analyses were performed using SPSS statistics 22.0.The results were recorded as an average ± standard deviation (SD). One-way analysis of variance (ANOVA) was used to assess the homogeneity of variance with significance level of 5% . A NanoDrop 2000 UV-Vis spectrophotometry  was used to determine the concentration and quality of DNA. The DNA samples were stored at –20°C until analysis. The V1-V2 hypervariable region of the 16S rRNA gene was used with primers and different 8-base barcodes and a Guanine were linked to the 5′ end of each primer. The information of primers was as follows: forward primer (5′-AGAGTTTGATYMTGGCTCAG-3′) and reverse primer (5′-TGCTGCCTCCCGTAGGAGT-3′) [https://github.com/najoshi/sickle). Mothur program was used for sequence demultiplexing and filtration. Lastly, sequence data used in this study has been submitted to Sequence Read Archive (SRA) with the accession number PRJNA 383079. The Shannon-Wiener index (H) was used to indicate the microbial species diversity of activated sludge [Activated sludge samples were collected from each reactor at the stable period in triplicate for microbial analysis. Processes contained DNA extractions, 16 S rRNA gene PCR amplifications and PCR product purifications. The total genomic DNA was extracted by the Fast DNAGAGT-3′) . The purd sludge .4+-N and TN fluctuated during the first 60 days. After that, the removal of COD, NH4+–N and TN tended to be stable. In most instances, the operation of reactors would achieve a stable stage after an adaptation time of at least two SRT in the biological process [Due to the microbial adaptation to the reactor condition, removal of COD, NH process . The ave4+–N removals were all over 90% in each sample (p > 0.05), but the removals of TN decreased from 64.04% to 53.19% (p < 0.05) and there was no obvious difference in R1, R2 and R3 of TN removal (p > 0.05). The results indicated that the selected NSAIDs of environmental concentration had little effect on COD and NH4+–N removals, but decreased TN removal. It seems that TN removal more easily affected than COD removal. A possible explanation of unchanged COD removal is that the sum of heterotrophs responsible for organic matter removal were not affected by the addition of selected NSAIDs of environmental concentration, and the decreased TN removal might be due to the decrease of denitrifying microorganisms. Similarly, Zhang et al. [4+–N removals appeared unchanged (p > 0.05) with addition of 5 and 50 μg L-1 tetracycline and sulfamethoxazole.As shown in g et al.  used SBRThe selected NSAID removals in the stable stage are gathered in The elimination of selected NSAIDs was contributed to various removal mechanisms including sorption, biodegradation and abiotic degradation. DCF, IBP and NPX contain carboxyl groups belonging to acidic functional groups, which could decrease the surface pH to increase their absorption coefficient . Many st-1) increased from 25.50±8.87 (R0) to 46.62±8.79 (R1), 52.15±1.20 (R2) and 49.02±4.95 (R3), respectively. The results indicated that environmentally relevant concentrations of selected NSAIDs stimulated SOD activity, suggesting that the three NSAIDs could induce the oxidative stress of microorganisms in activated sludge. Oxidative stress response can also be used to indicate low to moderate toxicity of selected pharmaceuticals  by increasing activities of oxidative stress enzymes [SOD is a key antioxidant enzyme which could indicate the oxidative stress . SDH pla enzymes . Zhang e enzymes  reported-1) decreased from 25.25±7.14 (R0) to 19.72±1.33 (R1), 18.53±1.02 (R2) and 16.31±1.00 (R3)  . SDH exid Gunsch , who inv-1), which were 94.62, 114.13 and 105.35 mg g VSS-1 in R1-R3, respectively. The increase of EPS content with the combination of selected NSAIDs indicated that the mixtures of selected NSAIDs might improve the toxicity to microorganisms, which could stimulate microorganisms to produce more EPS content. It was found that EPS content increased to form a network structure outside cells protecting cells from the damage of tetracycline or sulfamethoxazole [2 to R3, which indicated that the NSAIDs mixtures might have already damaged the microorganism growths. This finding is also supported by the results of the decreased SDH activity with the addition of selected NSAIDs. Quan et al. [It was often accepted that extracellular polymeric substances (EPS) were the important components to evaluate when examining the physicochemical and biological properties of biomass . In thishoxazole . Delgadohoxazole  reportedhoxazole  or antibhoxazole . EPS conn et al.  also rep-1 erythromycin after 45 min. Similarly, there was a decrease of the live/dead cell distribution ranging from 16% to 10% with additions of 1 and 10 uM of ketoprofen, naproxen, carbamazepine and gemfibrozil indicating that four commonly occurring phACs affected membrane integrity [The ratio of Live/Dead cells in activated sludge was determined at the stable stage. The percentages of live cells in sludge samples are shown in ntegrity .-1 DCF), 1.53 (5 μg L-1 DCF+5 μg L-1 IBP) and 1.58 (5 μg L-1 DCF+5 μg L-1 IBP+5 μg L-1 NPX). The result indicated that environmental concentration of NSAIDs could stimulate the bacterial diversity. Zhang et al. [-1 tetracycline and sulfamethoxazole. Huang et al. [-1 of tetracycline to investigate bacterial diversity, showing that microbial diversity increased after tetracycline addition. In fact, with the increase of pharmaceutical concentration to 10 mg L-1, the bacterial diversity would be inhibited [The Shannon-Wiener index was used to represent bacterial diversity, which was 1.39 (the control), 1.49  in R1 and R2, while the Proteobacteria decreased from 38.71% to 27.46% in R3 and the Bacteroidetes increased from 6.65% to 9.71% in R3. The Actinobacteria abundance increased from 29.38% in R0 to 45.56% in R3. TM 7 abundance steadily decreased from R0 to R3 until it finally reached its lowest percentage of 6.93% in R3. The decrease of Proteobacteria indicated that Proteobacteria might not adapt in the presence of selected NSAIDs. Actinobacteria show an increase from R1 to R3, suggesting that Actinobacteria could adapt well with the presence of selected NSAIDs. Recently, Zhang et al. [Microbial community changes in activated sludge at phylum level are illustrated in g et al.  also repg et al. 3 might be explained by the increased concentration of the mixtures of selected NSAIDs. The explanation is supported by [Bacteroidetes are heterotrophic microorganisms and could degrade high molecular weight organic compounds like petroleum hydrocarbons . The higorted by , who fouorted by .Some special but not abundant bacteria (data not shown), such as Nitrospira, Firmicutes and Chloroflexi, were gradually increased, but others, like Armatimonadetes and Gemmatimonadetes, were gradually below the detection limit. The increase of some microorganisms was probably due to their ability to degrade pharmaceuticals. It was found that Nitrospira and Firmicutes served as an important function in the treatment of wastewater with pharmaceuticals . SimilarMicropruina makes up a large part in activated sludge, which kept the decreasing trend from 29.53% to 14.90%, 14.21% and 9.50% in R0, R1, R2 and R3, respectively. Micropruina, a glycogen-accumulating organism, initially was isolated from an activated sludge reactor, which could indicate the biological phosphorus removal activity [Nakamurella, also affiliated with Actinobacteria phylum, decreased from 1.31% (R0) to 0.46% (R3). Tian et al. [Micropruina and Nakamurella had the ability to accumulate energy-storage chemicals when they were exposed to harsh conditions. TM7_genera_incertae_sedis, Amaricoccus, Haliscomenobacter and Microlunatus were the dominant genera in all sludge samples, which increased with the addition of pharmaceuticals. Amaricoccus and Haliscomenobacter were reported capable of utilizing sulfamethoxazole as a secondary carbon source in combination with acetate [TM7_genera_incertae_sedis increased from 16.36% (R0) to 27.38% (R3), which indicated that the addition of pharmaceuticals could stimulate the abundance of TM7_genera_incertae_sedis. However, the contribution of TM7_genera_incertae_sedison in the aerobic decontamination of wastewater was not clear [Zoogloea, affiliated with Proteobacteria phylum, had an augmentation under the pressure of pharmaceuticals, increasing from 0.08% (R0) to 0.33% (R3). It was known that Zoogloea can block toxic contaminants using their exocellular matrix [Zoogloea was considered as a functional bacterium in a granular sludge membrane bioreactor with the addition of pharmaceuticals, which could degrade antibacterial and anti-inflammatory organic matter. The abundance of Desulfovibrio and Desulfobulbus were 0.01% in the control (R0), increasing to 0.53% and 0.17% in R3, which belong to sulfate-reducing bacteria [The heat map of bacterial abundance at the genus level is shown in n et al.  reported acetate . TM7_genot clear . In thisbacteria .The above observations indicated that selected NSAIDs affected not only microbial activities but also microbial community. Actinobacteria and EPS increased with the addition of selected NSAIDs. It might be concluded that Actinobacteria might play an important role in producing EPS. Zhu et al.  observedWith the presence of selected environmental concentrations of NSAIDs in SBRs for 130 d, wastewater treatment efficiencies were not affected except for the reduction of TN removal. The results of the ratio of Live/Dead cell and oxidizing enzymes activities provided that environmental concentrations of selected NSAIDs caused toxicity to microbial communities, and the mixtures of three NSAIDs improved the toxicity. EPS content was increased to protect microorganisms from selected NSAID toxicity. The Shannon-Wiener diversity index increased with the presence of selected NSAIDs, which indicated that the environmental concentration of NSAIDs stimulated microbial diversity. Proteobacteria, Actinobacteria, TM 7 and Bacteroidetes were the dominant species in the activated sludge. Actinobacteria and Bacteroidetes were enriched with the presence of selected NSAIDs.


The main objective of this study was to assess semen characteristics ofpatients with testicular cancer before cryopreservation and after thawing,to evaluate the consequences of this technique on sperm quality in patientswith testicular cancer.Five hundred eighty-nine samples from 543 patients with testicular cancerwere cryopreserved between 1995 and 2015, one aliquot per patient was usedfor a thawing test to assess the impact of cryopreservation on spermmotility; semen analysis was performed before cryo preservation and afterthawing, the result interpretation was carried out using the 2010 WorldHealth Organization (WHO) Laboratory Manual, and consent forms were signedby the patients for freezing and when sperm was used for reproductivepurposes.p < 0.00001, 95% CI 5.48-14.91), which represents a32% reduction; concerning the utilization of cryopreserved semen samples,only twelve patients (2.2%) used their frozen sperm for reproductivepurposes.Hypospermia was observed in 28.7% of samples, the median sperm concentrationwas 18 million/mL with 35% oligozoospermia; twenty-two patients (4.1%) hadazoospermia and 12.7% had severe oligozoospermia, the median sperm count was31.3 million and 261 semen samples (44.3%) were normal in all parametersaccording to the WHO; total motile sperm count before cryopreservation andafter thawing was 12 (0-412.2) and 7 (0-303.9) million sperm, respectively(An impairment in semen quality was found in almost half of the samples frompatients with testicular cancer, only few patients had azoospermia or severeoligozoospermia; sperm cryopreservation significantly reduces sperm motilityand total motile sperm count and very few patients use their frozen spermfor reproductive purposes. Testicular cancer is a rare tumor, accounting for 1% of malignancies in menworldwide, and its incidence continues to increase in most Caucasian populations,where it is the most commonly diagnosed malignancy in young patients  Laboratory Manualcriteria .Semen volume, sperm count and progressive motility were assessed and registeredbefore cryopreservation. Hypospermia (< 1.5 mL), oligozoospermia (< 15million/mL) and astenozoospermia (< 32% spermatozoa with progressive motility)were defined based on the fifth percentile cut-off, according to WHO definitions. Prewash®, USA) with Test-Yolk Buffer according to the manufacturer'sinstructions. TYB® contains 20% egg yolk, 12% glycerol and10µg/mL gentamicin sulfate. One dose per patient was used for a thawing testto assess the impact of cryopreservation on sperm motility. Progressive motility wasassessed and registered after thawing and TMSC before and after the procedure wasalso calculated.Semen samples were cryopreserved in doses of 0.5 to 1 mL aliquots in cryogenic tubes were normal prior to cryopreservation: sperm volume ≥1.5 mL, sperm count ≥ 15 million/mL and sperm progressive motility ≥32%. The mean number of years of the samples at the sperm bank was 6.6 ±4.4.The mean semen volume was 2.2 ± 1.1 mL. The semen volume was ≥ 1.5 mLin 420 samples (71.3%) and < 1,5 mL in 169 samples (hypospermia = 28.7%).The median sperm concentration was 18 million/mL (0 – 219.5). Twenty-two patients(4.1%) had azoospermia and 69 patients (12.7%) had severe oligozoospermia, definedas ≤ 1 million sperm/mL in native semen. Among samples with spermatozoa, 383had ≥ 15 million sperm/mL (65%) and 206 had < 15 million/mL(oligozoospermia = 35%). The median total sperm count was 31.3 (0 - 620.2) million.It was ≥ 39 million in 263 samples (44.7%) and < 39 million in 326 samples(55.3%).p < 0.00001, 95% CI 12.82-16.98), which means a37% reduction in progressive motility.The sperm progressive motility in fresh semen was ≥ 32% in 405 samples (68.8%)and < 32 in 184 samples (astenozoospermia = 31.2%). Sperm progressive motilityafter the thawing test was ≥ 32% in 38.2% of the samples and < 32 in 61.8%of the samples. In six patients no motile sperm was found before cryopreservationand 12 more males did not have motile sperm after the thawing test, yielding a totalof 18 patients without motile sperm (3.3%). As shown on p < 0.00001, 95% CI5.48-14.91), which means a 32% reduction in TMSC (The median TMSC before cryopreservation and after thawing was 12 (0-412.2) and 7(0-303.9) million, respectively  and 3 samples were discarded becausepatients were reported dead. The total discard rate was 2.2%.The mean age of the patients in this study, as in other larger series, confirms thattesticular cancer affects young males  could be explained because some males recover spermatogenesisand do not need the cryopreserved sperm to impregnate their female partners and,sadly, because other patients succumb to the cancer, which happened only in 3 cases.The use rate in this study was lower than the mean percentage of 7% and 8%, reportedfor all male cancer patients by Unfortunately, as in other reports, the causes of the low use and discard rates (2.2%and 2.2%) cannot be exactly known in our study, because of the loss of follow up.For that reason, it cannot be concluded that the remaining patients, that still havecryopreserved samples, will need their frozen sperm in the future, although, we canassume that most of them could need it because the mean age of the patients at thetime of cryopreservation was only 26.9 years old and the mean number of years ofcryopreservation is 6.6 years.Due to the low use and discard rates, some studies have addressed thecost-effectiveness of sperm banking in male cancer patients, however, if we considerthe potential use rate, no conclusions can be obtained yet and more studies, with anaccurate follow up, should be performed in the future. In the meantime, spermcryopreservation for fertility preservation should to be offered to all adult menand post pubertal boys with testicular cancer, before cancer treatment onset,because it is simple, it does not mean a delay in the oncology treatment and is aneffective way for fertility preservation.


Significant associations between air pollutants and two types of hospital visits were observed. The estimated increase in overall outpatient visits associated with each 10 µg/m3 increase in air pollutant concentration ranged from 0.48% (O3 at lag 2) to 11.48% (SO2 with 2-day moving average); for overall inpatient visits ranged from 0.73% (O3 at lag 7) to 17.13% (SO2 with 8-day moving average). Our results also suggested a heterogeneity of the health effects across different outcomes and in different populations. The findings in present study indicate that even in Shenzhen, a less polluted area in China, significant associations exist between air pollution and daily number of overall outpatient and inpatient visits.Nowadays, air pollution is a severe environmental problem in China. To investigate the effects of ambient air pollution on health, a time series analysis of daily outpatient and inpatient visits in 2015 were conducted in Shenzhen (China). Generalized additive model was employed to analyze associations between six air pollutants (namely SO Ambient air pollution was at least suspected to cause adverse health effects, which was estimated to be responsible for more than 2 million deaths annually and 6.4 years of lost life worldwide . Exposur2), ozone (O3), sulfur dioxide (SO2) and particulate concentrations. Air pollutants including NO2, SO2 and particulate matter less than 2.5 µm in aerodynamic diameter (PM2.5) have also been reported to be risk factors of hospital admissions for cardiovascular diseases [A broad epidemiological studies have shown that increased ambient air pollutant concentrations are associated with excess daily mortality , hospitadiseases , hypertediseases  and respdiseases . For exadiseases  found th3, particulate matter less than 10 µm in aerodynamic diameter (PM10), and NOx on hospital visits for stroke in Southern Sweden where pollutant concentrations were rather low. Increased risk for ischemic stroke hospital visits at certain level of PM10 has been observed, whereas no consistent associations were found for ischemic stroke and O3 or NOx. Consequently, particularly in China, there is evidence of associations between certain diseases and air pollutions where air pollution concentrations are high, whereas the studies on health effects of air pollutions in less polluted areas are insufficient.Furthermore, most previous studies focused on heavily polluted areas such as Beijing or Shanghai whereas associations between air pollutant concentrations and health effect metrics were less addressed, especially in China. For heavily polluted areas, Guo et al. ,11 condu10 and PM2.5 [2 [3 [2, carbon monoxide (CO), NO2, O3, PM10 and PM2.5 were analyzed with a time series analysis.Shenzhen, a less polluted city of China, is a part of the Pearl River Delta region. With the development of industrialization and urbanization, different severe air pollutants, such as PMnd PM2.5 ,16, NO2 PM2.5 [2  and O3 [.5 [2 [3  have appThe ratio of zero records was greater or equal to mean of that for all hospitalsThe ratio of outliers  was greater or equal to mean ratio of outliers +2 standard deviationsThe coefficient of variation was greater or equal to mean ±2 standard deviationsSituated at a degree south of the Tropic of Cancer, south of China, Shenzhen has a warm, humid subtropical climate, and is less polluted due to geographical location, climatological parameters and low degree of industrialization. To evaluate the health effect of air pollution in Shenzhen, data on daily hospital outpatient and inpatient visits from 1 January 2015 to 31 December 2015 were collected from Center for Disease Control and Prevention (CDC) of Shenzhen. 25,185 records of outpatient and inpatients visits for a total of 69 hospitals in Shenzhen, including a pediatric, an ophthalmological and a cardiovascular hospital, were obtained. Most of general hospitals in Shenzhen are open regularly all day from Monday to Sunday, however several special hospitals could be close on holidays, for which records of zero outpatient and inpatient visits could be observed. To improve the reliability of analysis, 17 hospitals that meet the following standards were removed for further analysis:Records of the remaining 52 hospitals was further filtered with mean ±2 standard deviations criteria.2, CO, NO2, O3, PM10 and PM2.5 were included in this study. If data of air pollutants were missed on a given day, the missing values would be calculated with the average concentration computed from the remaining data. Of note, the air pollution data was representative to analyze the exposure of city population. Daily temperature, humidity and barometric pressure data were also collected from Shenzhen Meteorological Bureau website to adjust the effects of air pollution.The daily concentrations of ambient air pollutants in 2015 were obtained from Shenzhen Environmental Protection Bureau website. There are 19 fixed monitoring stations in the city, which are distributed in six administrative areas and four new areas in Shenzhen. Daily average concentrations of monitoring stations on SOIn present study, Poisson regression using a generalized additive modeling technique was performed to analyze the associations between ambient air pollutant concentrations and outpatient and inpatient visits. The dependent variables were the overall hospital daily count of outpatient and inpatient visits. In most analyses, the 3-day moving average pollutant concentration (the average of concentrations today (lag 0), yesterday (lag 1), and 2 days ago (lag 2) were modeled . To furt3 increase in air pollutants were further derived from estimated RRs, as observed during the study period. All statistical tests were two-sided. Only those independent variables with a test values of p < 0.05 were considered statistically significant. In addition, all the analysis was performed with R 3.2.3 on a Linux server.The anti-log of the regression coefficients for the major pollutants in the generalized additive models is a rate ratio, also interpreted as relative risk (RR). Increased risk (RR−1 * 100%) and the associated 95% confidence intervals (95% CI) for per 10 µg/m2, CO, NO2, O3, PM10, and PM2.5 were 8.33 µg/m3, 850.45, 33.36, 55.53, 49.11, and 29.87 µg/m3, respectively, wherein all the air pollutants were lower than the national primary ambient air quality standard in China .The average daily outpatient visits for 49 hospitals were 100,495 . The average daily inpatient visits were 2540 with a maximum of 3348 and a minimum of 1756. Air pollutant measurements were available for 365 days, of which the daily average concentrations of SOThe increased risk and the associated 95% CI for each air pollutant (at different lags) were evaluated by controlling the influence of temperature, relative humidity, pressure and day of the week. 3 increase in air pollutants at different lags were also summarized in 3 increase in air pollutants were 11.48% (95% CI: 6.32–16.89%) for SO2, 4.38% (95% CI: 2.25–6.56%) for NO2, 1.28% (95% CI: 0.76–1.80%) for O3, 1.52% (95% CI: 0.90–2.13%) for PM10, and 2.36% (95% CI: 1.45–3.28%) for PM2.5, respectively. Estimates from this distributed lag generalized additive model suggested that there were both immediate and lagged effects for these air pollutants. For all pollutants except CO, the pollutant concentrations on the day of outpatient visits (lag 0) as well as within 5-day moving average concentrations were significantly associated with overall outpatient visits. Interestingly, marginally reduced risk has been observed between CO and overall outpatient visits. As for overall inpatient visits, increased health risk effects were found between air pollutants consisting of SO2, NO2, O3, PM10, PM2.5 and inpatient visits, with highest increase in visits associated with each 10 µg/m3 increase in air pollutants being 17.13% (95% CI: 6.13–29.26%) for SO2, 3.66% (95% CI: 0.63–6.77%) for NO2, 1.70% (95% CI: 0.59–2.84%) for O3, 2.20% (95% CI: 1.01–3.41%) for PM10, and 3.27% (95% CI: 1.51–5.07%) for PM2.5. Among the above associations, the strongest associations between air pollutants and inpatient visits was found at 8-day moving average pollutant concentration. For the other associations (CO), the effects on hospital inpatient visits were not statistically significant at any lags of CO.The overall association estimate for per 10 µg/m3 increase in air pollutant concentration and 95% CI were estimated similarly by controlling temperature, relative humidity, pressure, time and day of the week. This study also calculated increase estimates for day-specific lags (lags 0–7), and day-specific moving average concentrations from 2 to 8 days for different categories of hospitals to assess the health effects of ambient air pollution. For general hospitals, all the pollutants investigated in this study were significantly associated with outpatient visits, with a maximum of 13.65% (95% CI: 5.47–22.46%) increase in visits for each 10 µg/m3 increase in 2-day moving average concentration of SO2. Meanwhile, air pollutants except CO significantly increased risk of inpatient visits, which confirmed to results of overall inpatient visits. For pediatric hospital, no significant associations have been found between outpatient visits and air pollutants, while the risk estimates of pollutants except O3 suggested strong relations between air pollution and inpatient visits. Increase in pediatric hospital inpatient visits associated with each 10 µg/m3 increase in air pollutant concentrations ranged from 0.16%  to 27.94% . The results also showed that SO2, NO2, O3, PM10, and PM2.5 displayed significant associations for both outpatient and inpatient visits of ophthalmological hospitals. CO increased risk for outpatient visits but did not significantly affect inpatient visits of ophthalmological hospitals. Analyses of outpatient and inpatient visits for cardiovascular hospital revealed that air pollutants except CO increased risk for outpatient visits, while only NO2 were observed to be strongly associated with inpatient visits.A total of 49 hospitals have been divided into four categories, namely general hospitals, pediatric hospital, ophthalmological hospital and cardiovascular hospital. Generalized additive models have performed separately on data of four categories of hospitals. Thereafter, associations with each 10 µg/m2, NO2, O3, PM10, as well as PM2.5, and two types of hospital visits were observed. The estimated increase in overall outpatient visits associated with each 10 µg/m3 increase in air pollutant concentrations ranged from 0.48% (O3 at lag 2) to 11.48% (SO2 with 2-day moving average); for overall inpatient visits ranged from 0.73% (O3 at lag 7) to 17.13% (SO2 with 8-day moving average). For general and ophthalmological hospitals, the strength of the associations is consistent with estimates of overall outpatient and inpatient visits, while different results have been obtained for pediatric and cardiovascular hospitals.The present study analyzed the hospital visits (outpatient and inpatient visits) data obtained from Shenzhen CDC to investigate associations between major air pollutants and hospital inpatient and outpatient visits over a period of 12 months. Significant associations between air pollutants including SO2, CO, NO2, O3, PM10, and PM2.5. SO2 is a traditional pollutant of industrial origin related to the combustion of coal and other fossil fuels. Consistent with the previous findings, our study demonstrated that the daily outpatient and inpatient visits were significantly associated with the concentration of SO2 [2. Increases in various types of admission would elevate the overall hospital admission, which might explain the significant associations between SO2 and overall outpatient and inpatient visits in our study.While ambient air pollution consists of a complex mixture of compounds, the study focused on SOn of SO2 ,21. A lin of SO2 , asthma n of SO2 ,23 and an of SO2 ,25 were Our study results shown that CO only had significant estimated associations with inpatient visits to the pediatric hospital, which partially agreed with the previous studies. Pan et al.  found th2 emission are coal and oil fired power plants and gasoline powered motor vehicle engines. The results of this study shows that increase of NO2 concentrations has a statistically significant association with outpatient and inpatient visits for all categories of hospitals. It is in agreement with studies that focused on hospital visits for specific diseases [2 elevation and asthma admission, which support our findings in this study.The main sources of ambient NOdiseases . In bothdiseases  and spatdiseases , robust 3 is a highly reactive gas which might induce bronchial inflammation, constriction of the airways and decrease lung function. The findings in our study have demonstrated strong associations between O3 and outpatient visits of general, ophthalmological and cardiovascular hospitals, while yielding inconsistent results for inpatient visits of pediatric and cardiovascular hospitals. Similarly, the previous studies have not yielded consistent results on associations between O3 and certain type of hospital admissions. Exposures to O3 have been previously reported to be associated with asthma admission and emergency department visits [3 in North America [3 increase in O3 has been reported for total respiratory disease after controlling for potential confounders [3 in Taiwan [3 might be confounded by different types of admission to hospitals, which could explain the inconsistent results obtained in this study.Ot visits . In cont America . For resfounders . Howevern Taiwan . The eff10 and PM2.5 are reported to be the major indicators of air pollutants which have direct negative bearings on human health. In our study, PM10, and PM2.5 were associated with increased likelihood of hospital outpatient and inpatient visits with every 10 µg/m3 increase in pollutant concentrations. Both PM10 and PM2.5 are heterogeneous mixture of small solid or liquid particles with varying compositions in the atmosphere, which would impact the outpatient and inpatient visits in a quite similar pattern. For specific disease risk evaluation, research studies found no consistent results between PM10 and asthma admissions [2.5 has been found to increase the daily outpatient visits in respiratory hospitals , while PM10 was not significantly associated with daily outpatient visits of the same hospital [10 were associated with outpatient visits for asthma [10 on outpatient visits [PMmissions . Increashospital . Pan et r asthma . Hwang at visits . These rMost of previous studies have focused on air pollutants on specific diseases of certain hospitals. The analysis conducted in this study evaluated the associations between different air pollutants and overall outpatient and inpatient visits. A major strength of the study is the high-quality data obtained from the Shenzhen with a high coverage of all hospitalized outpatient and inpatient visits. Since the database includes various types of visits in multiple hospitals and different air pollutant data that are highly representative, we can rule out the possibility of selection bias. Particularly, since the data were obtained from a historical database and collected sufficient information, recall bias was avoided.There were still several potential limitations in our study. First, though several potential confounders were adjusted in the generalized additive models, a bunch of possible confounding variables such as seasonal effect, family history, occupational exposures were not included in present study. Second, self-treatment with alternative services was not included. Therefore, the extent of the issue may have been considerably underestimated. Finally, potentially inaccurate data in the records could increase the estimation error in statistical analysis.In conclusion, the present study provides evidence that ambient air pollution exerted increased health risk effects on health and increased certain types of hospital outpatient and inpatient visits. These findings reinforce the importance of air pollution controls and disease prevention in less polluted areas, and warn the public about the atmospheric factors that could impact public health. This study also provides insight into the planning of clinical services and emergency contingency response for air pollution exposures.


Hepatitis C virus (HCV) infection is a pandemic causing disease; more than 185 million people are infected worldwide. An HCV antibody (Ab) prevalence of 6.0% was estimated in Central African countries. The study aimed at providing HCV prevalence estimates among pregnant women in Rwanda.HCV surveillance through antibody screening test among pregnant women attending antenatal clinics was performed in 30 HIV sentinel surveillance sites in Rwanda.Among 12,903 pregnant women tested at antenatal clinics, 335  tested positive for HCV Ab. The prevalence of HCV Ab in women aged 25–49 years was 2.8% compared to 2.4% in women aged 15–24 years ; This proportion was 2.7% [2.37–2.94] in pregnant women in engaged in non-salaried employment compared to 1.2% [0.24–2.14] in those engaged in salaried employment . The proportion of HCV Ab-positive co-infected with HIV was estimated at 3.9% (13 cases). Women in urban residence were more likely to be associated with HCV-infection  compared to those living in rural setting.HCV is a public health problem in pregnant women in Rwanda. Few pregnant women were co-infected with HCV and HIV. Living in urban setting was more likely to associate pregnant women with HCV infection. The global prevalence of hepatitis C virus (HCV) infection was estimated between 1.2 and 3.8% according to World Health Organization (WHO) Global Burden Disease (GBD), with more than 185 million people infected worldwide . The regA study conducted in specific sub-Saharan African countries estimated a high prevalence of HCV 6.0%) in central African countries. In North Africa, Egypt has the highest HCV prevalence 17.5%) followed by Morocco (7.7%)  were identified HCV Ab-positive.The prevalence of HCV-screened positive was 2.4% 95% CI: 1.6–3.2] among single pregnant women, 2.7% [95% CI: 2.3–2.9] among married pregnant women, and 3.9% [95% CI: 1.2–6.5] among separated, divorced or widowed pregnant women. The prevalence of HCV-screened positive was higher in pregnant women with low education level (illiterate and primary education level) compared to those with high education level (secondary and university education level): 2.7% [95% CI: 2.4–3.0] for illiterate pregnant women or pregnant women with primary education level vs. 1.8% [95%CI: 2.0–2.4 with secondary or university level]. Prevalence of HCV-screened positive was higher among pregnant women in unsalaried employment compared to pregnant women in salaried employment with 2.7% [95%CI: 2.4–3.0] and 1.2% [95%CI: 0.2–2.1] respectively . The proportion of HIV-positive among HCV Ab-positive pregnant women in ANC sentinel surveillance sites was (3.9%).The HCV prevalence among pregnant women in sentinel sites in Rwanda was similar to the overall HCV prevalence in sub-Sahara African countries (3.0%) and the prevalence of HCV in Central African region (2.0%) . It was The HCV and HIV co-infection was low among HCV-positive pregnant women in Rwanda. The proportion of the co-infection was lower compared to published studies in sub-Sahara countries (16.0%) and in Central African region (6.0%). A Brazilian study published in 2009 reported 7.0% of HCV-positive pregnant women were co-infected with HIV-1 . In EuroA significant difference in odds of having HCV was observed among pregnant women in urban residence compared to rural residence. That is, the HCV risk was higher in the urban than the rural women. The assumption behind this situation is the usual location of key population in urban setting than in rural ones.In our study, there was no evidence to suggest a significant association between HIV and HCV infections. Similar observations were made in a study conducted in Kigali among adult HIV-positive persons .The co-infection of HIV and HCV is associated with high mortality due to liver diseases compared to mono-infection . TherefoThis study had several limitations, namely: The survey was part of the antenatal sentinel sites sero-surveillance and therefore findings are applied to pregnant women in sentinel sites and cannot be generalized to the whole population in Rwanda or to pregnant women in other sub-Saharan African countries. Secondly, due to the small number of HCV and HIV co-infected pregnant women in our survey, it was not possible to assess the magnitude of this co-infection in selected socio-demographic characteristics sub-groups. Thirdly, in the present survey, Abbott ARCHITECT system is a screening test with high sensitivity. Therefore, in the context of our study, this screening test that was originally used in blood transfusion services to minimize hepatitis C transmission from blood donors; we may have some false HCV Ab-positive results.HCV-infection is a public health burden among pregnant women in Rwanda. This study provides a platform to inform policymakers and stakeholders the need to accelerate progress in treatment access and global prevention of HCV infections.Further advanced studies of HCV in this group and in the general population are needed to explore detection of Antigens and Antibodies and how they inform the diagnosis of acute and active HCV infections.


AAA observed were verified by confirmatory imaging using standard ultrasound or computed tomography. Cardiovascular risk factors were determined. The prevalence of AAA was computed as the sum of previously-known aneurysms, aneurysms detected by the screening program and model-based estimated undiagnosed aneurysms. We screened 1,010 men, with mean age of 71.3 (SD 6.9) years; 995 (98.5%) men had normal aortas and 15 (1.5%) had AAA on Vscan®. Eleven out of 14 AAA-cases (78.6%) had AAA on confirmatory imaging (one patient died). The total prevalence of AAA was 2.49% (95%CI 2.20 to 2.78). The median aortic diameter at diagnosis was 3.5 cm in screened patients and 4.7 cm (p<0.001) in patients in whom AAA was diagnosed incidentally. Multivariate logistic regression analysis identified coronary heart disease  as the independent factor with the highest odds ratio. A screening program led by trained family physicians using hand-held ultrasound was a feasible, safe and reliable tool for the early detection of AAA.We determined the feasibility of abdominal aortic aneurysm (AAA) screening program led by family physicians in public primary healthcare setting using hand-held ultrasound device. The potential study population was 11,214 men aged ≥ 60 years attended by three urban, public primary healthcare centers. Participants were recruited by randomly-selected telephone calls. Ultrasound examinations were performed by four trained family physicians with a hand-held ultrasound device (Vscan Abdominal aortic aneurysms (AAA) are dilatations of the aorta measuring ≥ 3 cm in diameter, commonly involving the infrarenal portion . AAA areUltrasonography is the gold standard tool for AAA screening due to its simplicity, safety, validity, cost-effectiveness, reproducibility and public acceptance, and is used in all studies that include screening programs.Miniaturized ultrasound devices date back to the 1970s . HoweverIn 2005, the U.S. Preventive Services Task Force recommended one-time AAA ultrasound screening in male ever-smokers aged 65–75 years. Recently, a systematic review of four population-based screening trials –22 by thThe aim of this study was to assess the accuracy and reliability of a screening program led by PHC family physicians using a hand-held ultrasound device to determine the prevalence of AAA and associated cardiovascular diseases in a Mediterranean population.We carried out a prospective, interventional study in which participants were screened in PHC centers by family physicians using hand-held-ultrasound to diagnose AAA.The prospective study population consisted of patients assigned to three urban, public PHC centers in Barcelona city  in June 2013. The inclusion criteria were male sex and age ≥ 60 years. The main difference in our study with respect to existing screening programs is the reduction from 65 years to 60 years of age. The main reason for this was to increase the years of life gained in patients with a possible AAA aged 60–64 years. Patients were recruited by randomly-selected telephone calls. One investigator called patients at random once a week to invite them to participate. Random selection was made by systematic sampling, considering an equal probability of selection for each patient. Self-referred patients were also accepted. Informative leaflets were made available in PHC center waiting rooms and entrances and physicians’ offices. In addition, a short video about the screening program was shown on televisions located in waiting rooms. Individuals interested in participating were contacted by PHC centers or their family physicians to schedule a hand-held ultrasound examination. We aimed to recruit the maximum number of participants (around 20 patients per week) during the study period (from June 2013 to October 2014) in clinical practice setting.All ultrasound examinations were carried out in PHC centers by four family physicians  who received 25 hours of ultrasound training from two hospital radiologists . The training included theoretical training on the basic acquisition, obtention and interpretation of the images. All four physicians were then evaluated by the radiologists for their capacity to measure aortic diameters and to diagnose AAA.®, General Electric, USA). The device weighs 390 g and measures 135×73×28 mm, and has a screen size of 8.9 cm. It offers two-dimensional grey scale and live color Doppler imaging. The bandwidth ranges from 1.7 to 3.8 MHz and is adjusted automatically . Limited examinations, either due to a poor ultrasound window or to a large amount of air, were excluded from the final analysis. Standardized measurements were made using the external-to-external wall method  and aortThe primary outcome was to determine the feasibility of a PHC AAA screening program using hand-held ultrasound. Additional outcomes were: 1) to determine the risk factors associated with AAA, and 2) to estimate the total prevalence of AAA in males aged ≥ 60 years, computed as the sum of previously-known AAA recorded in the medical record, AAA detected by the screening program  and model-based, estimated, undiagnosed AAA.2), abdominal circumference (cm), systolic and diastolic blood pressure (mmHg), total cholesterol (mg/dl), high-density lipoprotein (mg/dl), low-density lipoprotein (mg/dl), triglyceride (mg/dl), creatinine (mg/dl), glycated hemoglobin (%) and estimated glomerular filtration rate by modified diet in renal disease (ml/min/m2).Sociodemographic and biochemical variables were collected from the medical record in patients with a valid ultrasound measurement and included: age (years), body mass index (kg/m2), physical activity classified as sedentary lifestyle, moderate exercise, or intense exercise  or medians [interquartile range (IQR)]. Continuous variables were analyzed using the Student's evalence . An asymevalence .Of 11,214 male patients aged ≥ 60 years, 1,367 (12.2%) were invited by randomly selected telephone calls, of which 420 were excluded . There were 165 self-referred patients, of whom 10 with a history of AAA were excluded. Therefore, 1,102 men had a scheduled visit for screening, of whom 1,024 (92.9%) attended. Ten examinations (1.0%) were excluded due to poor ultrasound visibility and 4 (0.4%) due to large amounts of air (limited examination). Thus, 1,010 men were finally studied .2, abdominal circumference 101.8 (SD 10.5) cm, systolic blood pressure 131.6 (SD 13.8) mmHg, total cholesterol 187.6 (SD 34.6) mg/dl and creatinine 1.1 (SD 0.2) mg/dl. Of 465 men with a glycated hemoglobin measurement, 429 (92.2%) had HbA1c < 8%: 99 (10.6%) patients out of 671 had a Modified Diet in Renal Disease < 60 ml/min/m2.The mean age of the 1,010 men was 71.3 (SD 6.9) years, of which 794 (78.6%) patients were aged 65–84 years. The mean body mass index was 27.6 (SD 3.6) kg/mCardiovascular risk factors are shown in The median examination time was 4 [IQR 3–5] minutes. Median aortic diameters were 1.8 [IQR 1.7–2.1] cm (xiphoid process), 1.7 [IQR 1.6–1.9] cm (pre-bifurcation) and 1.8 [IQR 1.7–2.0] cm . With respect to size , 995 (98Patients with AAA were aged between 66 and 85 years. The median aortic diameter at diagnosis was 3.5 cm [IQR 3.2–3.6]. The AAA diameter was 3.0 to 3.5 cm in 10 patients (66.7%) and 3.6 to 4.1 cm in 5 (33.3%). In all AAA cases, the diagnosis was verified by standard ultrasound or computed tomography, except for one patient who died before confirmatory imaging. Age, aortic size, risk factors and confirmatory imaging of patients with AAA are shown in The association between AAA and risk factors is shown in During the study period, 12 AAA cases were identified among non-screened men. These 12 patients with AAA combined with the 160 with a history of AAA yielded a prevalence of 1.7% (95%CI 1.5 to 1.9) of AAA diagnosed without screening. The mean age of these patients at diagnosis was 70.8 (SD 7.3) years. Of the 172 patients, 110 were incidentally detected (64%), and 89 (51.7%) had a history of AAA repair. Median time from diagnosis to surgery was 145 [IQR 20.8–719.8] days. At diagnosis, the median aortic diameter in non-screened patients with AAA was 4.7 [IQR 3.7–5.5] cm, greater than the median aortic diameter at diagnosis in screened patients (p<0.001).Model-based estimates showed 96 undiagnosed AAA in non-screened men, with an estimated prevalence of around 0.93% (95%CI 0.74 to 1.12). The sum of previously known AAA, AAA detected by the screening program and model-based estimated undiagnosed AAA was 279 patients. Therefore, the overall estimated prevalence of AAA in men aged ≥ 60 years was 2.49% (95%CI 2.20 to 2.78) in the Spanish study population.This is the first Spanish study of a PHC screening program using hand-held ultrasound. The estimated overall prevalence of AAA was 2.49% in men aged ≥ 60 years. Only one study, in Western Australia, has analyzed the prevalence of AAA according to place of birth : men borPatients in our screening program had a median aortic diameter of 3.5 [IQR 3.2–3.6] cm compared with 4.7 [IQR 3.7–5.5] cm (p<0.001) in patients diagnosed incidentally. The probability of a ruptured aneurysm is directly proportional to size, and a significant difference of 12 mm may be a very strong argument in favor of a PHC AAA screening program to avoid a large number of patients with ruptured AAA in whom a prior opportunity for detection is missed .®, found that sensitivity, specificity and predictive values were 100%, in agreement with our previous validation study [® for AAA screening had a diagnostic accuracy and abdominal aorta measurement comparable to conventional ultrasound (Pearson’s correlation = 98%). The false positive rate of 21.4% (3/14) found in the current study could be considered high. However, it should be noted that one of these patients had aortic ectasia (patient #4) and another had a luminal thrombus (patient #5). Thus, it could be argued that these are not truly false positives and that the sensitivity is, therefore, higher. Moreover, there is no consensus on the best methods of measuring the diameter of the abdominal aorta [® has a good diagnostic accuracy for AAA screening [Hand-held ultrasound is getting increasing interest in various medical fields and strata . Bonnafyon study . Dijos eon study  found thal aorta . The inncreening ,44.Although we expanded the age range downwards to ≥ 60 years, the prevalence of AAA was very similar to that observed in studies in the general population. A Cochrane systematic review  of AAA sWith respected to the reduction in mortality, in a Danish study application of a screening program meant 107 years of life gained after 10 years in screened patients. The relative risk associated with screening was highly favorable to the intervention group, with a reduction in AAA-attributable mortality , fewer AAA ruptures  and fewer urgent surgeries . The study concluded that AAA screening in Danish men aged 64–73 years reduced AAA-specific mortality by 67%, and the number of patients needed to be included in a screening program to save one life was 352 patients . Public Despite the safety of ultrasound, its use is not widespread in PHC for AAA screening. Although several intervention strategies have been proposed in primary care to improve compliance with AAA screening , ultraso2. We analyzed a smaller sample size than other studies, detecting 11 cases of AAA. Although our findings are similar to those of other reports with larger sample sizes, the results of the multivariate model for the assessment of risk factors and the estimate of the expected prevalence should be interpreted with caution. In the 11 patients aged ≥ 65 years in whom small AAA  were detected, follow up with a new abdominal ultrasound at 12 months was necessary. However, the present study only shows the results of the first exploratory ultrasound. Larger studies should be conducted to improve recruitment strategies and increase the number of participants.Our study had some limitations. The combination of self-referred men and men chosen randomly could potentially lead to considerable heterogeneity in the cohort. In our study, most of the 1024 participants screened were randomly selected (85%). In fact, random selection was considered to avoid selection bias . Self-referred patients were also accepted for ethical reasons. Thus, in our opinion, the heterogeneity of our cohort was not meaningful. Although ultrasound is the gold-standard for the detection of AAA, obese patients generally present a worse acoustic window, making it more difficult to visualize an aorta that is located in a much deeper plane. The solution could be technological: in populations with a high prevalence of obesity, technologically- improved ultrasound machines with a larger screen size are necessary. In fact, in our study, the mean BMI in patients with a non-diagnostic study was 35.8 kg/m® led by family physicians in PHC centers suggests that the program was easy to administer, rapid, and successful in the early detection of AAA. Hand-held ultrasound could be a feasible tool for the PHC family physician, as it is easily repeatable and safe, without a risk of radiation. In the near future, technological advances may further improve the portability, reliability, and accuracy of hand-held ultrasound devices.In conclusion, this prospective study of a screening program for AAA using VscanS1 File(XLSX)Click here for additional data file.


Campylobacter infection is a common cause of diarrhea among international travelers. We studied antibiotic resistance patterns among Campylobacter isolates obtained from international travelers according to travel destination. Three collections of isolates obtained from international travelers between 2007 and 2014  were used. Isolates were tested for minimal inhibitory concentration (MIC) values (E-test macromethod) for fluoroquinolones, macrolides, tetracyclines, amoxicillin–clavulanic acid, and meropenem. Single isolates from 261 travelers were available; median (IQR) age was 25.4 (4–42) years, 85.8% were symptomatic (information for 224 patients available). Overall resistance to ciprofloxacin was 60.9%, ranging from 50.8% in Africa to 75.0% in Asia. Resistance to erythromycin was 4.6%, with the highest rate observed for Southern Asia . A total of 126 isolates (48.3%) were resistant to tetracycline. No resistance to amoxicillin–clavulanic acid or meropenem was detected. Ciprofloxacin resistance tended to increase over time (53.9% in 2007 versus 72.2% in 2014), erythromycin resistance remained stable . Most (86.2%) ciprofloxacin-resistant isolates had MIC values ≥32 mg/l, and all erythromycin-resistant isolates had MIC values ≥256 mg/l. Co-resistance to ciprofloxacin and erythromycin was observed in 11 (4.2%) isolates, seven of which came from Southern Asia. Among all regions of travel, more than half of Campylobacter isolates were resistant to ciprofloxacin. Overall resistance to erythromycin was below 5% but reached 15.2% in Southern Asia.The online version of this article (doi:10.1007/s10096-017-3032-6) contains supplementary material, which is available to authorized users. Campylobacter spp., in particular Campylobacter jejuni and Campylobacter coli, are the most common cause of bacterial enteritis in humans worldwide. Typically Campylobacter infection causes self-limiting diarrhea with or without fever [ut fever . The sevut fever –3. In inut fever  to 20% iut fever , 6.Campylobacter isolates obtained from international travelers between 2007 and 2014, compared to a previous study over the time period 1994–2006 [The objective of the present study was to update antibiotic resistance rates among Campylobacter isolates consecutively obtained from international travelers were tested. A first collection one (n = 194) was obtained from the post-travel policlinic at the Institute of Tropical Medicine (ITM) Antwerp. The second collection (n = 84) consisted of clinical isolates obtained from the Laboratoire de la Porte de Hal (LHUB-ULB), Brussels. The third collection (n = 37) formed part of a National Survey in Belgium, performed by the National Reference Centre for Campylobacter in Brussels (NRC). Methods of isolation and identification of isolates differed between collections. A detailed description of patient population, study period, and methods used for each collection can be found in Supplement Three collections of human intestinal  one n = 94 was obEnterobacteriaceae were used. For levofloxacin EUCAST breakpoints for Enterobacteriaceae are the same as those proposed for Helicobacter pylori, which is often considered as a Campylobacter-related organism [Upon retrieval from storage isolates were subcultured onto Columbia agar with 5% sheep blood and incubated at 42 °C for 24 h. Antibiotic susceptibility testing was performed in batch using Mueller Hinton agar with 5% sheep blood and incubated in a microaerophilic atmosphere at 42 °C for 24 to 48 h. Minimal inhibitory concentration (MIC) values for ciprofloxacin, levofloxacin, azithromycin, erythromycin, tetracycline, doxycycline, amoxicillin–clavulanic acid and meropenem were determined by E-test macromethod . This panel was chosen in accordance with EUCAST guidelines and recommendations of the European Centre for Disease Prevention and Control (ECDC) [organism . For merorganism . QualityTravel destinations were grouped in regions and continents according to the United Nations geoscheme . Demogra2-test) or Fisher’s exact test. Trends over time were assessed using the Mantel–Haenszel extension of the chi-square test for trends. A p-value <0.05 was considered significant. For convenience, differences between the three collections are only discussed separately in the text if they are significant.Proportions of resistance rates over time and for different geographical regions were assessed for significance using the Pearson’s chi-square test  and those that did not grow upon retrieval (n = 11). The LHUB-ULB collection consisted of 83 available isolates, representing 98.8% of 84 isolates from patients with a recent travel history. In addition, 36 (97.3% of 37) isolates from participants with a recent travel history were available through the National Survey. C. jejuni was most prevalent , followed by C. coli ; nine isolates (3.4%) were not identified beyond the genus level. There was no significant difference in geographical distribution between the different Campylobacter species.Of the 267 available isolates, six were excluded because information about travel destination was not available, resulting in a total of 261 isolates recovered from 261 patients. At ITM, 142 isolates were available for analysis, representing 73.2% of all 194 non-duplicate isolates obtained at this site during the study period: non-available isolates included those that had not been stored  age of the entire cohort was 25.4 (4–42) years; 50.4% of patients were male. Median ages differed between the three collections: 28.5, 2.5, and 49.0 years for the ITM, LHUB-ULB and National Survey collections respectively, with 8.4%, 58.3%, and 16.7% of patients younger than 5 years respectively. Complete data about a history of diarrhea and fever were available for 243 (93.1%) and 249 (95.4%) patients respectively: most  suffered from diarrhea, whereas 88 (33.7%) reported fever and 84 (31.8%) reported both. Seventeen patients were asymptomatic; in these participants, the isolate was obtained during routine post-travel consultation. Table eoscheme . More thp = 0.03).A total of 77 isolates (29.5%) were susceptible to all antibiotics tested, of which 43 isolates (55.8%) were obtained from Africa. Overall resistance to ciprofloxacin was 60.9%, ranging from 50.8% in Africa to 75.0% in Asia. Lowest resistance rates — although consistently above 33% of isolates — were observed for Eastern, Western, and Middle Africa. Overall resistance to erythromycin was 4.6%, and ranged from 2.4% in Europe to 10.0% in Asia. The highest rate was observed for Southern Asia (15.2%), with 6/7 resistant isolates recovered from India. A total of 126 isolates (48.3%) were resistant to tetracycline, with small variations between regions. There was no resistance to amoxicillin—clavulanic acid or meropenem. During the study period, ciprofloxacin resistance rate was higher in 2014 (72.2%) than in 2007 (53.9%). When comparing the present ciprofloxacin resistance rate to that of 2001–2006 as tested in our previous study [p = 0.2).For erythromycin, no increase over time was noted . Resistance rates to ciprofloxacin were similar for both species. Co-resistance to ciprofloxacin and erythromycin was observed in 11 (4.2%) isolates, seven of which came from Southern Asia .Resistance rates for levofloxacin and ciprofloxacin were identical  with complete overlap. Most 86.2%) ciprofloxacin-resistant isolates (86.2%) had MIC values ≥32 mg/l . Most travelers were symptomatic.Campylobacter isolates were resistant to ciprofloxacin, with highest rates observed for Asia and the Americas. Data about resistance to fluoroquinolones among Campylobacter spp. in humans varies, with levels as high as 93.1% in China [Overall, more than half of in China  to 6.6% in China , and wasgyrA) and an efflux system mechanism [More than 80% of ciprofloxacin-resistant isolates had MIC values ≥32 mg/l. As 32 mg/l is the upper value at which the E-test is truncated, the actual MIC value of these isolates was not assessed. It should be remembered that peak concentration of fluoroquinolones in feces largely exceeds those reached in blood after standard-dose therapy. This can explain why fluoroquinolone treatment of campylobacteriosis may result in clinical cure despite apparent resistance of the isolate (23). Molecular mechanisms for fluoroquinolone resistance (not assessed in the current collection) include point mutations in the genes encoding DNA gyrase (echanism –15.C. jejuni human isolates were resistant to erythromycin [C. coli (up to 66% [C. jejuni (less than 10%), but this was not confirmed in the present study, possibly because of low numbers of C. coli isolates.Resistance to macrolides as assessed in the present study was particularly high in Asia, with a resistance rate of 15.2% in Southern Asia. These results confirm the high level of resistance previously reported in a Pakistani urban environment in 2012, where 27.0% of hromycin . Resistap to 66% ) compareThe 15.2% resistance rate among isolates from Southern Asia, as well as the occurrence of combined ciprofloxacin–erythromycin resistance in India and Nepal (representing 7/11 co-resistant isolates), argue for caution and continued surveillance. Resistant isolates displayed high-level resistance for both antibiotics . This is indicative of resistance conferred by point mutations in the domain V in the 23S ribosomal RNA gene . Our resCampylobacter fetus [In the present collection, there was no resistance against amoxicillin–clavulanic acid. Data about resistance levels to amoxicillin–clavulanic acid are scarce, as it is currently not a treatment of choice . Resistaer fetus .The study was conducted with different isolate collections, originating from different time periods and various methods of isolation and identification. Additionally, the numbers of isolates varied between years, and 32 isolates obtained at ITM between October 2010 and August 2011 had not been stored. Detailed and complete clinical data  were only available for a subset of patients. Finally, the number of isolates obtained from some regions were too small to draw reliable conclusions.Conversely, combining different isolate collections made it possible to cover different profiles and destinations of travelers; the resulting numbers of isolates were sufficient to generate a geographic picture as well as an over-time evolution. In that regard, the study can be considered as representative for travel medicine, and in addition provides proxy antibiotic surveillance data from regions in the world where microbiological surveillance is scarce.Campylobacter diarrhea is rarely indicated, as it is self-limiting and will usually cure within 5–7 days of onset of symptoms. In the case of patients whose symptoms are severe or persistent, immunocompromised patients, and in those with extra-intestinal infections, antibiotic treatment is needed. The present resistance rates confirm that, if indicated, azithromycin is the antibiotic of choice in travel-associated diarrhea contracted worldwide [Antibiotic treatment for Campylobacter isolates recovered from symptomatic travelers returning from all regions were resistant to ciprofloxacin, precluding its use in the treatment of Campylobacter diarrhea. Overall resistance to erythromycin was below 5%, but as high as 15.2% in Southern Asia. The World Health Organization recently ranked fluoroquinolone-resistant Campylobacter spp. as a high-priority pathogen for the development of new antibiotics [In conclusion, more than half of ibiotics . This neESM 1(DOCX 14 kb)ESM 2(XLSX 60 kb)


The addition of 1 mg L-1 sodium hypochlorite resulted in an immediate free chlorine residual of 0.16 mg L-1, which inactivated 3.5 log10 units of Ebola virus in 20 seconds. Further inactivation was not evident due to the rapid consumption of the chlorine residual. Elevating the pH to 11.2 was found to significantly increase viral decay over ambient conditions. These results indicate the high susceptibility of the enveloped Ebola virus to disinfection in the presence of free chlorine in municipal wastewater; however, we caution that extension to more complex matrices (e.g. bodily fluids) will require additional verification.Concerns have been raised regarding handling of Ebola virus contaminated wastewater, as well as the adequacy of proposed disinfection approaches. In the current study, we investigate the inactivation of Ebola virus in sterilized domestic wastewater utilizing sodium hypochlorite addition and pH adjustment. No viral inactivation was observed in the one-hour tests without sodium hypochlorite addition or pH adjustment. No virus was recovered after 20 seconds (i.e. 4.2 log Ebola virus infected individuals may generate up to nine liters of potentially infectious liquid waste per day. Previous recommendations were to directly dispose of this waste into a sanitary sewer or latrine; however, release of infectious virus raised the concern of environmental transmission through unintentional contact with contaminated wastewater. One possibility to reduce or eliminate the release of infectious virus is disinfection of Ebola virus contaminated liquid waste. A hurdle to making recommendations for liquid waste disinfection is the lack of data on disinfection efficacy. Here we demonstrate that Ebola virus in municipal wastewater is highly sensitive to disinfection in the presence of free chlorine. In addition, elevating the pH to 11.2 significantly increased the rate of decay over neutral pH conditions. These results provide a basis to develop recommendations for the disinfection of Ebola virus contaminated wastewater. The conmacaques .90 (time for 90% inactivation) of Ebola virus in sterilized wastewater to be 2.1 days [ad hoc liquid waste disinfection approaches prior to disposal [The World Health Organization initially recommended that liquid waste from Ebola patients be directly disposed into the sanitary sewers or latrines without disinfection . The rec2.1 days , which i2.1 days . Additio2.1 days . Previou2.1 days . In respdisposal . The Wordisposal .Currently, the disinfection kinetics of Ebola virus in liquid is unknown. In a previous evaluation of Ebola virus disinfection on surfaces, sodium hypochlorite at 0.01% and 0.1% was found to be ineffective but 0.5% and 1% sodium hypochlorite removed viable virus in five minutes . AdditioThe overarching study goal was to determine the disinfection of Ebola virus in municipal wastewater, of direct relevance to wastewater management in an outbreak scenario. Our scope was limited to municipal wastewater and did not consider the disinfection of Ebola virus in concentrated human waste . It should be noted that disinfection under high organic load , which is not the focus of the current manuscript, would require hyper-chlorination, which has been suggested to inconsistently achieve adequate disinfection and would require additional experimental verification . In the 7.3 TCID50 mL-1) [5 TCID50 mL-1 for both Ebola virus disinfection experiments and pH inactivation experiments. All experiments were completed in triplicate at 20°C. Ebola virus titration and cultivation were performed as previously described [50 mL-1.Wastewater samples were collected from a municipal wastewater treatment plant as described previously  and ship50 mL-1)  was diluescribed . The lim-1. Samples were then taken at the indicated time points and chlorine demand immediately quenched by the addition of sodium thiosulfate. The ‘time zero’ sampling point was taken approximately 20 seconds following the addition of chlorine to enable sample mixing.For disinfection experiments, sodium hypochlorite (Acros Organics) was added to two milliliter vials of the wastewater/virus suspension at initial doses of 0, 1, 5, and 10 mgLThree pH values were evaluated for pH inactivation experiments: 6.9 (intrinsic), 4.3, and 11.2. pH values were found to be stable for the time period evaluated. The tested pH values were chosen to be below the previously recognized Ebola virus glycoprotein stability down to pH = 4.8  and to b0 was the modeled initial chlorine residual. The concentration-time exposure was then calculated for each sampling time point by integrating the area under the modeled chlorine residual curve at each time point.Chlorine residuals in both the untreated and the gamma-irradiated wastewater were experimentally determined outside of the Biosafety Level 4 facility using a Hach Free Chlorine test kit (method 10069) in triplicate. Chlorine residual was experimentally found to be dose dependent . To deteStatistical analyses and graphing were completed with Prism 7.0a and Microsoft Excel 2011.p < 0.05); however, the chlorine decay was more rapid in irradiated wastewater compared to the wastewater without irradiation, suggesting that testing in the irradiated wastewater would demonstrate less rapid viral inactivation than would be observed in the non-irradiated wastewater at the same applied dose. Chlorine residual was found to be dose-dependent . Data for the 0 and 1 mg L-1 conditions from the 105 TCID50 mL-1 virus concentration is shown in 10 TCID50 mL-1 in 20 seconds), no further viral removal was observed in the 1 mg/L condition, likely due to the low concentration of free chlorine  of viral particles remain not particle associated , 30.Despite the end of the most recent Ebola virus epidemic, concerns remain regarding the potential transmission of emerging enveloped viruses via water , highligS1 Table50 mL-1. Limit of detection for each replicate was 0.75 log TCID50 mL-1.All values log TCID(DOCX)Click here for additional data file.S2 Table50 mL-1. Limit of detection for each replicate was 0.75 log10 TCID50 mL-1.All values log TCID(DOCX)Click here for additional data file.S1 Fig(DOCX)Click here for additional data file.S2 FigNo residual detected at later time points.(DOCX)Click here for additional data file.S3 Fig(DOCX)Click here for additional data file.S4 Fig(DOCX)Click here for additional data file.S5 Fig(DOCX)Click here for additional data file.


Testing was completed at baseline, 3, and 6 weeks of training. During each testing session, ultrasound muscle thickness and echo intensity, 1RM strength, maximal voluntary isometric contraction (MVIC) strength, and contractile properties of the quadriceps femoris were measured. Percent voluntary activation (VA) and electromyographic (EMG) amplitude were measured during MVIC, and during randomly ordered isometric step muscle actions at 10–100% of baseline MVIC. There were similar increases in muscle thickness from Baseline to Week 3 and 6 in the 80 and 30% 1RM groups. However, both 1RM and MVIC strength increased from Baseline to Week 3 and 6 to a greater degree in the 80% than 30% 1RM group. VA during MVIC was also greater in the 80 vs. 30% 1RM group at Week 6, and only training at 80% 1RM elicited a significant increase in EMG amplitude during MVIC. The peak twitch torque to MVIC ratio was also significantly reduced in the 80%, but not 30% 1RM group, at Week 3 and 6. Finally, VA and EMG amplitude were reduced during submaximal torque production as a result of training at 80% 1RM, but not 30% 1RM. Despite eliciting similar hypertrophy, 80% 1RM improved muscle strength more than 30% 1RM, and was accompanied by increases in VA and EMG amplitude during maximal force production. Furthermore, training at 80% 1RM resulted in a decreased neural cost to produce the same relative submaximal torques after training, whereas training at 30% 1RM did not. Therefore, our data suggest that high-load training results in greater neural adaptations that may explain the disparate increases in muscle strength despite similar hypertrophy following high- and low-load training programs.We examined the neuromuscular adaptations following 3 and 6 weeks of 80 vs. 30% one repetition maximum (1RM) resistance training to failure in the leg extensors. Twenty-six men (age = 23.1 ± 4.7 years) were randomly assigned to a high- (80% 1RM;  The neuromuscular system displays a high degree of adaptability and responds to resistance training in a manner that ultimately results in enhanced force or torque production. The specific neuromuscular adaptations responsible for the increase in muscle strength are often broadly grouped as morphological and neural  should be utilized in order to maximize hypertrophy and strength in response to a resistance training program NSCA, . HoweverAlthough, high- and low-load training to failure may elicit similar hypertrophy, high-load training may be superior for enhancing muscle strength , and contractile twitch properties, following 3 and 6 weeks of 80 vs. 30% 1RM resistance training to failure in the leg extensors. Based on previous studies  were analyzed and reported in this manuscript. To be eligible, each participant must have been between the ages of 19 and 35, free from any current or ongoing musculoskeletal injuries or neuromuscular disorders involving the hips, knees, or ankles, and could not have completed any regular or formal resistance training for at least 6 months prior to the start of the study. This study was approved by and carried out in accordance with the recommendations of the University of Nebraska-Lincoln's Institutional Review Board for the protection of human participants . Prior to any data collection, all participants signed an informed consent form and completed a health history questionnaire.n = 13) or low-load  resistance training group, and familiarized with the testing procedures. Participants completed leg extension resistance training to failure 3 times per week for 6 weeks. Testing was completed at baseline, 3, and 6 weeks of training. All participants completed a total of 21 visits, and each visit was separated by 24–96 h and occurred at the same time of day (±2 h). During each testing session, ultrasound, muscle strength, EMG amplitude, VA, and contractile properties were measured. The participants were asked to refrain from any outside resistance exercise for the duration of the study.A randomized, repeated measures, between-group, parallel design was used for this study. Participants were randomly assigned to either a high-  ultrasound-imaging device  and a multi-frequency linear-array probe . Images were obtained while the participants were lying in the supine position with their legs extended, relaxed, supported on the table, and their feet braced. Great care was taken to ensure that consistent, minimal pressure was applied with the probe to limit compression of the muscle. To enhance acoustic coupling and reduce near field artifacts, a generous amount of water-soluble transmission gel was applied to the skin. To account for the possibility of non-uniform hypertrophy . Prior to all analyses, each image was scaled from pixels to cm using the straight-line function in Image-J. The muscle thickness of the leg extensors  was measured as the distance (cm) from the adipose tissue-muscle interface to the muscle-bone (for the VM) or muscle-muscle interface  with a custom-fitted load cell . The axis of rotation of the dynamometer head was aligned with the lateral epicondyle of the right femur. The seat was tilted back so that there was 120° between the thigh and the trunk to expose the femoral triangle for location of the femoral nerve trunk and delivery of the electrical stimuli. The leg was flexed to 90° between the leg and the horizontal plane, which was used for both voluntary and evoked isometric muscle actions.The participants completed 2, 3 s warm-up leg extension muscle actions at 50 and 75% of their perceived effort with 30 s of rest between each muscle action. Following the warm-up and 2 min of rest, participants completed 2, 4–5 s MVICs of the leg extensors with 2 min of rest between each muscle action. On each attempt subjects were instructed to contract as “hard and fast” as possible when the investigator said “go.” Loud, verbal encouragement was given during each MVIC.*100 . Three to five s after these submaximal step muscle actions, a doublet stimulus was administered at rest (potentiated twitch). An MVIC was also completed after the 2, 4–5 s MVICs, but prior to the submaximal step muscle actions, during which a doublet stimulus was also applied. Three to five s after this MVIC, a potentiated twitch was evoked. Percent voluntary activation was calculated as (1-[superimposed twitch/potentiated twitch])PP) and twitch force were achieved by increasing amperage in 20–100 mA increments until a plateau in twitch force and MPP were observed after three consecutive amperage increases. To ensure a supramaximal stimulus, 120% of the stimulus used to evoke the maximal twitch force and MPP was used to evoke the leg extensor muscles with 3 singlet stimuli while the participant was relaxing. Doublet stimuli (200 ms duration square-wave impulse at 100 Hz) were then used to assess voluntary activation. Two men, 1 from the 80% 1RM group and 1 from the 30% 1RM group, were unable to tolerate the doublet stimuli used to determine VA. One of these men (from the 30% 1RM group) was also unable to tolerate the singlet stimuli used to elicit the M-wave and examine contractile properties. Therefore, for VA, a sample size of 12 for each group was used for analyses. For normalized EMG amplitude during voluntary contractions and for the M-wave and contractile properties, a sample size of 13 and 12 were used for the 80 and 30% 1RM groups, respectively.Transcutaneous electrical stimuli were delivered via a cathode-anode arrangement using a high voltage , constant-current stimulator . The cathode was a probe placed over the femoral nerve in the lateral most corner of the femoral triangle and the anode was a disposable surface electrode  fixed over the greater trochanter. Optimal stimulation probe location was determined by delivering single low-amperage exploratory stimuli (20–40 mA) with the cathode probe. Probe location was selected based on visual inspections of the twitch force and the compound muscle action potential (M-wave) amplitudes that were displayed on an external computer screen. Once the location was determined, the skin was marked and all further stimuli were delivered at that location. Maximal peak-to-peak M-wave amplitude  were placed on the VL, VM, and RF muscles of the right thigh with an inter-electrode distance of 30 mm. For the VL, the center of the bipolar electrode pair was placed at 66% of the distance between the anterior superior iliac spine (ASIS) and the lateral superior border of the patella  and force signals were recorded during all isometric testing. The EMG and force signals were sampled simultaneously at 2 kHz with a Biopac data acquisition system , recorded on a personal computer, and processed off-line with custom written (N.D.M.J.) software . The EMG signals were amplified  using a differential amplifier  with a common mode rejection ratio of 110 dB min and an impedance of 2M Ω, and zero-meaned. The voluntary and evoked EMG signals were digitally filtered (zero-phase shift 4th-order Butterworth filter) with a band-pass of 10–499 and 10–999 Hz, respectively. The force signals were low-pass filtered (zero-phase shift 4th-order Butterworth filter) with a 15 Hz cutoff. The force obtained from the load cell (N) was multiplied by the lever arm length (m) to calculate torque (Nm). All subsequent analyses were completed on the filtered and scaled signals.dt/dt) and rate of relaxation (−dt/dt) were calculated as the positive and negative peaks of the first derivate torque signal (Nm s−1), respectively. In addition, MPP was calculated as the peak-to-peak amplitude (μV). M-wave duration (MDUR) was calculated as the time (ms) from the onset to cessation of the M-wave.During the evoked muscle actions, peak twitch torque (PTT) was calculated as the highest 5 ms torque value (Nm) obtained after the onset of the evoked twitch. The peak rate of torque development   to either 80 or 30% of 1RM. Participants were instructed to perform all repetitions through a complete range of motion. A metronome  was set to 1 Hz, and participants were instructed to perform the concentric and eccentric phases corresponding with each tick of the metronome so that the concentric and eccentric phases were ~1 s. Verbal instruction and encouragement were provided during each set. Failure was defined as the inability to complete another concentric muscle action through the full range of motion. Two min of rest were provided between sets for both conditions (80 and 30% 1RM). The weight utilized during training was adjusted based on the new 1RM established at the week 3 testing session. The total repetitions performed by each subject were calculated as the sum of the repetitions completed for each set across all sets and exercise sessions. Total time under load was calculated for each subject as the sum of the times to completion for each set across all sets and exercise sessions. Total exercise volume was calculated for each subject as the sum of the product of the number of sets performed, the repetitions completed, and the weight lifted and expressed in total weight (kg) lifted across all exercise sessions.http://www.myfitnesspal.com, MyFitnessPal LLC, San Francisco, CA) that provided calculations of absolute daily energy intake , as well as protein (g), carbohydrate (g), and fat (g) intakes. The average intakes for energy, protein, carbohydrate, and fat across each 3-day period were recorded.Participants completed a 3-day dietary log prior to the training period. Participants were instructed to write down all food and drink (except water) consumed on the first 3 days of the training period. These data were entered into an online dietary analysis software  were used to compare groups (80% 1RM vs. 30% 1RM) for muscle thickness, echo intensity, 1RM strength, MVIC strength, VA during MVIC, EMGQAMP during MVIC, PTT, PTT:MVIC ratio, +dt/dt, −dt/dt, MPP, and MDUR using the respective Baseline scores as the covariate and the Week 3 and/or Week 6 scores as the dependent variable. Multiple a priori planned comparisons were used to analyze the differences within conditions (80% 1RM and 30% 1RM) from Baseline to Week 3 to Week 6 using one-way analyses of variance (ANOVAs) and follow-up Sidak-Bonferroni dependent samples t-tests.Six separate independent samples QAMP during the submaximal isometric step muscle actions. For VA and EMGQAMP, three-way mixed factorial ANOVAs (time [Baseline vs. Week 3 vs. Week 6] × torque [10% vs. 20% vs. 30% vs. 40% vs. 50% vs. 60% vs. 70% vs. 80% vs. 90% vs. 100% MVIC] × group [80 vs. 30% 1RM]) were used to analyze VA and EMGQAMP during the 10 common isometric torques at each visit. Because these initial analyses revealed time × group interactions, we collapsed the data across torque (for EMGQAMP and VA) and applied an ANCOVA model utilizing the respective Baseline scores as the covariate and the Week 3 or Week 6 scores as the dependent variable. Differences within conditions (80% 1RM and 30% 1RM) from Baseline to Week 3 to Week 6 were then analyzed using one-way analyses of variance (ANOVAs) and follow-up Sidak-Bonferroni corrected dependent samples t-tests.Initially, an ANOVA model was used to assess VA and EMGt-test performed. In cases where the homogeneity of variances assumption was not met, the error term and degrees of freedom were adjusted using the Welch–Satterthwaite method. Partial eta effect sizes  were calculated for independent samples t-tests as described previously , from Week 3 to Week 6 , and from Baseline to Week 6 .There was no difference in the adjusted means for the 80 vs. 30% 1RM groups at Week 3 or Week 6 for muscle thickness Figure . In the p = 0.07; d = −0.71), from Week 3 to Week 6 , and from Baseline to Week 6 . In the 30% 1RM group, echo intensity did not change from Baseline to Week 3 , but decreased from Week 3 to Week 6 , and from Baseline to Week 6 .There was no difference in the adjusted means for the 80 vs. 30% 1RM groups at Week 3 or Week 6 for echo intensity Figure . In the p < 0.01; d = 2.10), from Week 3 to Week 6 , and from Baseline to Week 6  in the 80% 1RM group. In the 30% 1RM group, 1RM strength did not change from Baseline to Week 3 , but increased from Week 3 to Week 6  and from Baseline to Week 6 .The adjusted means for 1RM strength were significantly greater in the 80% than 30% 1RM group at Week 3 and Week 6 Figure . In the p = 0.02; d = 1.08), from Week 3 to Week 6 , and from Baseline to Week 6 . Whereas, in the 30% 1RM group, MVIC strength did not change from Baseline to Week 3 , but increased from Week 3 to Week 6  and from Baseline to Week 6 .The adjusted means for MVIC strength were significantly greater in the 80% than 30% 1RM group at Week 3 and Week 6 Figure . In the p = 0.22; p = 0.59; The adjusted mean for PTT was significantly greater in the 80% than 30% 1RM group at Week 3, but not at Week 6 Figure . Howevers Figure .Figure 9B). In the 80% 1RM group, PTT:MVIC was significantly lower at Week 3  and Week 6  than at Baseline; whereas there was no significant change in PTT:MVIC from Baseline to Week 3 or 6 in the 30% 1RM group , but did not change from Week 3 to Week 6  or Baseline to Week 6  in the 80% 1RM group. There was also a significant main effect for time in the 30% 1RM group  or Week 3 to Week 6 , but increased from Baseline to Week 6 . In the 30% 1RM group, VA increased from Baseline to Week 3 , but did not change from Week 3 to Week 6  and was not different from Baseline at Week 6 .There was no difference in the adjusted means for VA in the 80 vs. 30% 1RM groups at Week 3, but VA was greater in the 80% than 30% 1RM group at Week 6 Figure . In the QAMP in the 80 vs. 30% 1RM groups at Week 3 or Week 6 , did not change from Week 3 to Week 6 , and increased from Baseline to Week 6 . In the 30% 1RM group, there was a significant main effect for time . The adjusted means for VA during the submaximal isometric step muscle actions were lower in the 80% than 30% 1RM group at Week 3 (52.61 ± 1.70 vs. 59.88 ± 1.70%) and Week 6 (49.43 ± 1.73 vs. 54.71 ± 1.73%). In the 80% 1RM group, voluntary activation did not change from Baseline to Week 3  or Week 3 to Week 6 , but decreased from Baseline to Week 6 . In the 30% 1RM group, voluntary activation did not change from Baseline to Week 3 , decreased from Week 3 to Week 6 , but did not change from Baseline to Week 6 .There was no time × torque × group interaction (Voluntary activation (collapsed across time and group) increased in a quadratic fashion from 10 to 100% MVIC.p = 0.19; QAMP, but there were time × group .There was no significant time × torque × group interaction . The adjusted mean for EMGQAMP during the submaximal isometric step muscle actions was lower in the 80% than 30% 1RM group at Week 3 (3.33 ± 0.24 vs. 4.30 ± 0.25 %Mpp), and Week 6 (3.26 ± 0.26 vs. 3.91 ± 0.27 %Mpp). In the 80% 1RM group, EMGQAMP did not change from Baseline to Week 3  or Week 3 to Week 6 , but decreased from Baseline to Week 6 . However, there was no change in EMGQAMP from Baseline to Week 3 or 6 in the 30% 1RM group . Consequently, these data suggest that neural adaptations help explain the greater increases in muscle strength following training with 80% 1RM, despite the similar increases in muscle size following training with 80 and 30% 1RM.This was the first study to examine neuromuscular adaptations during maximal and submaximal contractions following 3 and 6 weeks of 80% 1RM vs. 30% 1RM resistance training to failure. The primary results indicated that, despite similar increases in muscle thickness from Baseline to Week 6 for the 80% 6.7%) and 30% 1RM (6.0%) groups Figure . Specifi% and 30%In the present study, muscle thickness increased by 6.7 and 6.0% in the 80 and 30% 1RM groups, respectively, with no difference between groups Figure . HypertrDamas et al.  recentlyr = 0.87) with increases in echo intensity. Hill and Millan (r = 0.88–0.92) to changes in skeletal muscle glycogen content following cycling exercise. Although, several previous studies have demonstrated decreases in echo intensity following chronic resistance training  and dynamic  strength increased from Baseline to Week 3 in the 80% 1RM group only and increased from Baseline to Week 6 in both the 80 and 30% 1RM groups Figures , 4A. How Figures . Thus, eVoluntary activation during MVIC increased 2.2% from Baseline to Week 3 and 4.3% from Baseline to Week 6 in the 80% 1RM group, and was greater for the 80% than 30% 1RM group at Week 6 Figure . FurtherQAMP during MVIC at Week 3 or Week 6 between the 80 and 30% 1RM groups . Conversely, EMGQAMP did not change in the 30% 1RM group. EMGQAMP was significantly lower in the 80% than 30% 1RM group at Weeks 3 and 6 across submaximal torque levels. Subsequently, much like VA, the EMGQAMP data suggested a reduced neural cost to produce the same absolute torques following training at 80% 1RM, but not 30% 1RM, especially at high torque levels  used to elucidate any potential underlying neural factors. Indeed, greater neural adaptations were observed after resistance training at 80% 1RM compared to the 30% 1RM group. Specifically, our data during maximal torque levels suggests that, after 6 weeks of training, 80% 1RM loads elicit greater increases in neural drive than 30% 1RM loads, while our data during submaximal torque levels suggests that resistance training at 80% 1RM increases the efficiency of muscle activation to a greater extent than 30% 1RM training.Six weeks of high- (80% 1RM) and low-load (30% 1RM) resistance training to failure elicited equivalent hypertrophy as measured by ultrasound. However, training at 80% 1RM induced greater strength gains, which has been demonstrated repeatedly (Campos et al., NJ was a substantial contributor to study concept and design, carried out data acquisition, analysis, and interpretation, and was the primary author. AM, EH, CS, and KC helped carry out data acquisition. TH contributed to study design and manuscript revision. JC was the primary manuscript reviser and a substantial contributor to study concept, study design, and interpretation. All authors approved the final version of this manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.