Emotion has a substantial influence on the cognitive processes in humans, including perception, attention, learning, memory, reasoning, and problem solving. Emotion has a particularly strong influence on attention, especially modulating the selectivity of attention as well as motivating action and behavior. This attentional and executive control is intimately linked to learning processes, as intrinsically limited attentional capacities are better focused on relevant information. Emotion also facilitates encoding and helps retrieval of information efficiently. However, the effects of emotion on learning and memory are not always univalent, as studies have reported that emotion either enhances or impairs learning and long-term memory (LTM) retention, depending on a range of factors. Recent neuroimaging findings have indicated that the amygdala and prefrontal cortex cooperate with the medial temporal lobe in an integrated manner that affords (i) the amygdala modulating memory consolidation; (ii) the prefrontal cortex mediating memory encoding and formation; and (iii) the hippocampus for successful learning and LTM retention. We also review the nested hierarchies of circular emotional control and cognitive regulation (bottom-up and top-down influences) within the brain to achieve optimal integration of emotional and cognitive processing. This review highlights a basic evolutionary approach to emotion to understand the effects of emotion on learning and memory and the functional roles played by various brain regions and their mutual interactions in relation to emotional processing. We also summarize the current state of knowledge on the impact of emotion on memory and map implications for educational settings. In addition to elucidating the memory-enhancing effects of emotion, neuroimaging findings extend our understanding of emotional influences on learning and memory processes; this knowledge may be useful for the design of effective educational curricula to provide a conducive learning environment for both traditional “live” learning in classrooms and “virtual” learning through online-based educational technologies. Emotional experiences are ubiquitous in nature and important and perhaps even critical in academic settings, as emotion modulates virtually every aspect of cognition. Tests, examinations, homework, and deadlines are associated with different emotional states that encompass frustration, anxiety, and boredom. Even subject matter influences emotions that affect one’s ability to learn and remember. The usage of computer-based multimedia educational technologies, such as intelligent tutoring systems (ITSs) and massive open online courses (MOOCs), which are gradually replacing traditional face-to-face learning environments, is increasing. This may induce various emotional experiences in learners. Hence, emotional influences should be carefully considered in educational courses design to maximize learner engagement as well as improve learning and long-term retention of the material . Numerousubjective approaches that assess subjective feelings and experiences; (2) behavioral investigations of facial expressions  activities tivities  in addittivities . The CNSThe aim of this current article was to highlight an evolutionary approach to emotion, which may facilitate understanding of the effects of emotion on learning and memory. We initially present the terminology used in affective neuroscience studies, describe the roles of emotion and motivation in learning and memory, and outline the evolutionary framework and the seven primary emotional system. This is followed by the emotional-cognitive interactions in the various brain regions that are intimately involved in emotion and memory systems. This is performed to define the congruent interactions in these regions are associated with long-term memory (LTM) retention. We then discuss the emerging studies that further our understanding of emotional effects deriving from different modalities of emotional content. This is followed by a discussion of four major functional neuroimaging techniques, including functional magnetic resonance imaging (fMRI), positron emission tomography (PET), electroencephalography (EEG), and functional near-infrared spectroscopy (fNIRS). We then present the important factors for consideration in experimental design, followed by a description of psychiatric disorders, such as depression and anxiety, which are emotionally charged dysfunctions that are strongly detrimental to cognitive performance. Our review ends with concluding remarks on the current issues and future research possibilities with respect to the efficient enhancement of educational practices and technologies.Subjective terms used in affective neuroscience include emotions, moods, feelings, affects and drives. Although emotion has long been studied, it bears no single definition. A review of 92 putative definitions and nine skeptical statements  suggestsEmotions describe a complex set of interactions between subjective and objective variables that are mediated by neural and hormonal systems, which can (a) give rise to affective experiences of emotional valence (pleasure-displeasure) and emotional arousal ; (b) generate cognitive processes such as emotionally relevant perceptual affect, appraisals, labeling processes; (c) activate widespread psychological and physiological changes to the arousing conditions; and (d) motivate behavior that is often but not always expressive, goal-directed and adaptive.Although this definition may be adequate for everyday purposes, it does not encompass some important aspects of emotional systems such as how emotions operate to create subjectively experienced feelings and how they control personality dimensions. Accordingly, Emotions are the psychoneural processes that are influential in controlling the vigor and patterning of actions in the dynamic flow of intense behavioral interchanges between animals as well as with certain objects that are important for survival. Hence, each emotion has a characteristic “feeling tone” that is especially important in encoding the intrinsic values of these interactions, depending on their likelihood of either promoting or hindering survival . Subjective experiential-feelings arise from the interactions of various emotional systems with the fundamental brain substrates of “the self,” that is important in encoding new information as well as retrieving information on subsequent events and allowing individuals efficiently to generalize new events and make decisions.He went further to propose seven primary emotional systems/prototype emotional states, namely SEEKING, RAGE, FEAR, LUST, CARE, PANIC/GRIEF, and PLAY that represent basic foundations for living and learning.accompanied by internal physiological changes in the body, specifically the viscera, including the heart, lungs, and gut, for maintaining or restoring homeostatic balances. Feelings are not commonly caused emotions. Because the generation of emotional feelings requires a neural re-mapping of different features of the body state in the CNS, resulting from cognitive “appraisal” where the anterior insular cortex plays a key integrative role  rather dependent on changes of the external environment or bodily states. Affects are subjective experienced emotional feelings that are difficult to describe, but have been linked to bodily states such as homeostatic drives (hunger and thirst) and external stimuli   . The lat, smell) . In addi, smell) ; this isoveractivity of the hypothalamic-pituitary-adrenal (HPA) axis, which results in both impaired synaptic plasticity and learning ability (incongruous situation (expectancy violation) refers to a discrepancy between prior expectations and the new information; it may drive a cognitive reset for “learned content” that draws one’s attention.The impact of emotion on learning processes is the focus of many current studies. Although it is well established that emotions influence memory retention and recall, in terms of learning, the question of emotional impacts remains questionable. Some studies report that positive emotions facilitate learning and contribute to academic achievement, being mediated by the levels of self-motivation and satisfaction with learning materials . Convers ability . Nonethe ability . Motivat ability . The terSimilarly, emotionally enhanced memory functions have been reported in relation to selective attention elicited by emotionally salient stimuli . During Homeostatic affects, such as hunger and thirst, are not considered prototype emotional states. Because homeostatic affects have never been mapped using ESB that arouse basic emotional responses   . Homeost intake) . To summplay situation or a threat situation (where RAGE and FEAR might be the appropriate system to recruit). Emotion offers preprogrammed but partially modifiable (under the secondary process of learning and memory) behavioral routines in the service of the solution of prototypical adaptive challenges, particularly in dealing with friend vs. foe; these routines are evolutionary extensions of homeostasis and embed a prediction beyond the current situation to a potentially future homeostatic benefit or threat. Thus, evolution uses whatever sources for survival and procreative success. According to all learning (secondary-process) is piggybacked on top of the “primary-process emotions” that are governed by “Law of Affect” . What now follows is an explanation of these CNS emotional-affective processing sub-levels and their inter-relationships.Evolution built our higher minds (the faculty of consciousness and thoughts) on a foundation of primary-process of emotional mechanism that preprogrammed executive action systems (the prototype emotions) rely on cognitive processing (interpretation) and appraisal in the organisms attempt to decipher the type of situation they might be in; in other words, how to deal with emotionally challenging situations, whether it is a rewarding’ and ‘punishing’ learning effects) and thinking at secondary and tertiary levels.The emotional operating system is an inherited and genetically encoded circuitry that anticipates key survival and homeostatic needs. Thus, animals and humans share primary emotional network at the subcortical level, which includes the midbrain’s periaqueductal grey (PAG) and VTA, basal ganglia , and insula, as well as diencephalon . Subcortical brain regions are involved in three sub-components of affects: (1) core emotional feelings ; (2) homeostatic drives/motivational experiences (hunger and thirst); and (3) sensory affects . Primary-process emotions are not unconscious. Strong emotion is intrinsically conscious at least in the sense that it is experienced even if we might mislabel it, or animal clearly is not able to attach a semantic label-these are simply not realistic standards for determining whether something is conscious or not conscious. Nonetheless, the emotional experiences guide behavior to promote survival and procreative success as well as mediate learning  processes via the mediation of emotional networks. This includes the basal ganglia , and the medial temporal lobe (MTL) including hippocampus as well as the entorhinal cortex, perirhinal cortex, and parahippocampal cortices that responsible for declarative memories. Thus, secondary processes of learning and memory scrutinize and regulate emotional feelings in relation to environmental events that subsequently refine effective solutions to living.Higher cognitive functions operate within the cortical regions, including the frontal cortex for awareness and consciousness functions such as thinking, planning, emotional regulation and free-will (intention-to-act), which mediate emotional feelings. Hence, cognition is an extension of emotion (just as emotion is an extension of homeostasis aforementioned). Tertiary processes are continually integrated with the secondary processes and reach a mature level (higher brain functions) to better anticipating key survival issues, thus yielding cognitive control of emotion via “top-down” regulation. In other words, brain-mind evolution enables human to reason but also regulate our emotions.Figure 2 demonstrates this cyclic homeostatic regulation.Psychologist overactivity of this system promotes excessively impulsive behaviors attended by manic thoughts and psychotic delusions. Moreover, massive lesion of SEEKING’s neural network , medial forebrain and anterior cingulate) lead to consciousness disorder, specifically akinetic mutism (AKM) syndrome that the patient appears wakeful, attentive but motionless  processing during WM . Simons basolateral complex of the amygdala (BLA) with other brain regions that are involved in consolidating memories, including the hippocampus, caudate nucleus, NAc, and other cortical regions. Thus, BLA activation results from emotionally arousing events, which appear to modulate memory storage-related regions that influence long-term memories  that contribute to the emotional enhancement of memory . Activatmemories . Memory memories . Moreovememories ; furthermemories . This suIn addition to attentional biases toward emotional content during memory encoding, emotionally arousing experiences have been found to induce the release of adrenal stress hormones, followed by the activation of β-noradrenergic receptors in the BLA, which then release epinephrine and glucocorticoids in the BLA, while enhancing memory consolidation of emotional experiences . Thus, tThe PFC is located in the foremost anterior region of the frontal lobe and is associated with higher-order cognitive functions such as prediction and planning of/for the future . MoreoveThe mPFC has been associated with anticipatory responses that reflect cognitive expectations for pleasant/unpleasant experiences  . SpecifiOther studies reported strong cognition-emotion interactions in the lateral prefrontal cortex with increased activity in the DLPFC, which plays a key role in top-down modulation of emotional processing . This inTable 1 summarizes cognitive-emotional functions associated with each sub-region of the PFC and corresponding Brodmann areas. Taken together, these findings indicate that the PFC is a key component in both cognitive and emotional processing for successful LTM formation and retrieval.Another study investigated the PFC’s role in emotional mediation, reporting that the right VLPFC provided cognitive resources for both emotional reappraisal and learning processes via two separate subcortical pathways: (i) a path through NAc appeared to greater reappraisal success (suppress negative emotion) and (ii) another path through the ventral amygdala appeared to reduced reappraisal success (boost negative experience). This result indicates the VLPFC’s role in the regulation of emotional responses  by retrieving appropriate information from memory . CertainAs discussed above, evidence indicates the neural mechanisms underlying the emotional processing of valence and arousal involve the amygdala and PFC, where the amygdala responds to emotionally arousing stimuli and the PFC responds to the emotional valence of non-arousing stimuli. We have thus far primarily discussed studies examining neural mechanisms underlying the processing of emotional images. However, recent neuroimaging studies have investigated a wider range of visual emotional stimuli. These include words , pictureanimate or inanimate and common or uncommon. The results revealed the activation of the amygdala in response to positive and negative valence  for pictures and words. A lateralization effect was observed in the amygdala when processing different emotional stimuli types. The left amygdala responded to words while either the right and/or bilateral amygdala activation regions responded to pictures. In addition, participants were more sensitive to emotional pictures than to emotional words. The mPFC responded more rigorously during the processing of positive than to that of negative stimuli, while the VLPFC responded more to negative stimuli. The researchers concluded that arousal-related responses occur in the amygdala, dmPFC, vmPFC, anterior temporal lobe and temporo-occipital junction, whereas valence-dependent responses were associated with the lateral PFC for negative stimuli and the mPFC for positive stimuli. The lateralization of the amygdala’s activation was consistent with that in other studies that also showed left-lateralized amygdala responses for words , even though all stimuli were consistent in terms of arousal levels . Subjector words  vs. righor words . Howeverrds  were used to investigate the modality effects deriving from emotional words and facial expressions as stimuli in healthy, native German speakers . German Table 2 summarizes studies on the brain regions that respond to standardized stimuli as cited above, and also for pictures of emotional facial expression or Pictures of Facial Affect (POFA), Affective Norms for English Words (ANEW) for emotional words, as well as for the International Affective Digitized Sound System (IDAS) for emotional sounds.Another group studied the impacts of emotion on memory using emotional film clips that varied in emotion with neutral, positive, negative and arousing contents . A subjeThe brain regions associated with cognitive-emotional interactions can be studied with different functional neuroimaging techniques  to examine hemodynamic responses (indirect measurement). EEG is used to measure brain electrical dynamics (direct measurement) associated with responses to cognitive and emotional tasks. Each technique has particular strengths and weaknesses, as described below.Functional magnetic resonance imaging is a widely used functional neuroimaging tool for mapping of brain activation as it provides a high spatial resolution (a few millimeters). fMRI is an indirect measure of hemodynamic response by measuring changes in local ratios of oxy-hemoglobin vs. deoxy-hemoglobin, typically known as a blood oxygenation level dependent (BOLD) signal . Dolcos hits > misses) was associated with neural activation of the bilateral amygdala, hippocampus, and parahippocampus, whereas a higher success rate for neutral retrieval is associated with a greater activity in right posterior parahippocampus regions  and positron-emitting-oxygen isotope tagged with water ([15O] H2O), etc. This technique identifies different neural networks involving pleasant, unpleasant and neutral emotions . PET uses positron-emitting radionuclides such as emotions . It thusUsing PET scanning demonstrated that emotional information enhances visual memory recognition via interactions between perception and memory systems, specifically with greater activation of the lingual gyrus for visual stimuli . The resIn a study of emotional self-generation using PET noted that the insular cortex, secondary somatosensory cortex, and hypothalamus, as well as the cingulate cortex and nuclei in the brainstem’s tegmentum, including PAG, parabrachial nucleus, and substantia nigra maintained current homeostasis by generating regulatory signals . PET scaElectroencephalography obtains high temporal resolution in milliseconds, portable, less expensive, and non-invasive techniques by attaching scalp electrodes to record brain electrical activity. Moreover, numerous studies reported that EEG is useful in mapping CNS cognitive and emotional processing. The technique offers a comprehensive range of feature extraction and analysis methods, including power spectral analysis, EEG coherence, phase delay, and cross-power analysis. One study examined changes in EEG oscillations in the amygdala during the consolidation of emotionally aroused memory processing that exhibited theta (4–8 Hz) activity , indicatfrontal asymmetry index by computing a ratio of differences in log-transformation power values between the left frontal and right frontal alpha power or , and the selection of electrodes is the homologous pairs (F3-F4/F7-F8). Thus, positive value indicates left frontal activity that associated with positive emotion/approach motivation and negative value indicates right frontal activity that associated with negative emotion/withdrawal motivation. In other words, greater right alpha power  than left alpha power  results in left frontal activity and vice versa. Another study reported greater alpha activity in the left frontal region  was associated with approach motivation, while the greater alpha activity in right frontal  was associated with withdrawal motivation  left PFC inhibits processing of negative/withdrawal-related distractors and (ii) right PFC inhibits processing of positive/approach-related distractors  vs. deoxygenated hemoglobin (deoxy-Hb) using optodes (light emitters and detectors) placed on the scalp . It is lexercise  conceptual issues is related to the fact that prefrontal cortex is an anatomically and functionally heterogeneous and complex region interacts with other cortical and subcortical structures during emotional processing  discrete emotional, and (2) dimensional emotions of valence, arousal, dominance and familiarity . The latx-point” scale allows participants to rate their own emotional responses. If a study does not seek to assess distinct emotional states but rather involves the assessment of two primary dimensions of emotion , then the Positive and Negative Affect Schedule (PANAS) is a recommended method  and fMRI/PET/fNIRS (indirect) have respective advantages and disadvantages. To overcome these limitations, simultaneous or combined dual-modality imaging (EEG-fMRI or EEG-fNIRS) can now be implemented for complementary data collection. Although functional neuroimaging works to identify the neural correlates of emotional states, technologies such as deep brain stimulation (DBS) and connectivity maps might provide new opportunities to seek understanding of emotions and its corresponding psychological responses.The neuroscience of cognition and emotion requires appropriate task designs to accomplish specific study objectives . EnvironNumerous neuroimaging studies cited thus far have indicated that emotions influence memory processes, to include memory encoding, memory consolidation, and memory retrieval. Emotional attentional and motivational components might explain why emotional content exhibits privileged information processing. Emotion has a “pop-out” effect that increases attention and promotes bottom-up instinctual impact that enhances awareness. Significant emotional modulation affects memory consolidation in the amygdala, and emotional content also appears to mediate memory encoding and retrieval in the PFC, leading to slow rates of memory lapse accompanied by the accurate recall. Moreover, cognitive and emotional interactions also appear to modulate additional memory-related CNS regions, such as the frontal, posterior parietal and visual cortices. The latter are involved in attentional control, association information, and the processing of visual information, respectively. Therefore, higher-level cognitive functions such as learning and memory, appear to be generally guided by emotion, as outlined in the Panksepp’s framework of brain processing .Neuroimaging findings also indicate the involvement of the PFC in emotional processing by indirectly influencing WM and semantic memory . This isBased on numerous previous findings, future research might take emotional factors more seriously and more explicitly in terms of their potential impact on learning. By monitoring the emotional state of students, the utilization of scientifically derived knowledge of stimulus selection can be particularly useful in the identification of emotional states that advance learning performance and outcomes in educational settings. Moreover, functional neuroimaging investigations now include single and/or combined modalities that obtain complementary datasets that inform a more comprehensive overview of neuronal activity in its entirety. For example, curiosity and motivation promote learning, as it appears cognitive network become energized by the mesolimbic-mesocortical dopamine system . In addition, the identification of emotional impact on learning and memory potentially has direct implications for healthy individuals as well as patients with psychiatric disorders such as depression, anxiety, schizophrenia, autism, mania, obsessive-compulsive disorder and post-traumatic stress disorder (PTSD) . To emphSubstantial evidence has established that emotional events are remembered more clearly, accurately and for longer periods of time than are neutral events. Emotional memory enhancement appears to involve the integration of cognitive and emotional neural networks, in which activation of the amygdala enhances the processing of emotionally arousing stimuli while also modulating enhanced memory consolidation along with other memory-related brain regions, particularly the amygdala, hippocampus, MTL, as well as the visual, frontal and parietal cortices. Similarly, activation of the PFC enhances cognitive functions, such as strategic and semantic processing that affect WM and also promote the establishment of LTM. Previous studies have primarily used standardized emotional visual, or auditory stimuli such as pictures, words, facial expression, and film clips, often based on the IAPS, ANEW, and POFA databases for emotional pictures, words and facial expressions, respectively. Further studies have typically focused on the way individuals memorize  emotional stimuli in controlled laboratory settings. To our knowledge, there are few objective studies that employed brain-mapping techniques to examine semantic memory of learning materials (using subject matter) in the education context. Furthermore, influences derived from emotional factors in human learning and memory remains unclear as to whether positive emotions facilitate learning or negative emotions impair learning and vice versa. Thus, several remaining questions should be addressed in future studies, including (i) the impact of emotion on semantic knowledge encoding and retrieval, (ii) psychological and physiological changes associated with semantic learning and memory, and (iii) the development of methods that incorporate emotional and motivational aspects that improve educational praxes, outcomes, and instruments. The results of studies on emotion using educational learning materials can indeed provide beneficial information for informed designs of new educational courses that obtain more effective teaching and help establish better informed learning environments. Hence, to understand how emotion influence learning and memory requires understanding of an evolutionary consideration of the nested hierarchies of CNS emotional-affective processes as well as a large-scale network, including the midbrain’s PAG and VTA, basal ganglia , and insula, as well as diencephalon  together with the MTL, including the hippocampus as well as the entorhinal cortex, perirhinal cortex, and parahippocampal cortices that responsible for declarative memories. Moreover, the SEEKING system generates positive subjective emotional states-positive expectancy, enthusiastic exploration, and hopefulness, apparently, initiates learning and memory in the brain. All cognitive activity is motivated from ‘underneath’ by basic emotional and homeostatic needs  that explore environmental events for survival while facilitating secondary processes of learning and memory.CMT drafted this manuscript. CMT, HUA, MNMS, and ASM revised this draft. All authors reviewed and approved 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.


The mammalian thalamocortical system generates intrinsic activity reflecting different states of excitability, arising from changes in the membrane potentials of underlying neuronal networks. Fluctuations between these states occur spontaneously, regularly, and frequently throughout awake periods and influence stimulus encoding, information processing, and neuronal and behavioral responses. Changes of pupil size have recently been identified as a reliable marker of underlying neuronal membrane potential and thus can encode associated network state changes in rodent cortex. This suggests that pupillometry, a ubiquitous measure of pupil dilation in cognitive neuroscience, could be used as an index for network state fluctuations also for human brain signals. Considering this variable may explain task-independent variance in neuronal and behavioral signals that were previously disregarded as noise. The mammalian thalamocortical system generates intrinsic activity reflecting different states of excitability, arising from changes in the membrane potentials of underlying neuronal networks. Fluctuations between these states occur spontaneously, regularly, and frequently throughout awake periods and influence stimulus encoding, information processing, and neuronal and behavioral responses. Changes of pupil size have recently been identified as a reliable marker of underlying neuronal membrane potential and thus can encode associated network state changes in rodent cortex. This suggests that pupillometry, a ubiquitous measure of pupil dilation in cognitive neuroscience, could be used as an index for network state fluctuations also for human brain signals. Considering this variable may explain task-independent variance in neuronal and behavioral signals that were previously disregarded as noise.Neural networks undergo constant state fluctuations provoked by changes of internally generated activity, even in the absence of external stimulation. These changing patterns of activity vary on slow and rapid time scales and shape the ongoing signal as well as neuronal responses on incoming sensory information.At the behavioral level, these states can be associated with different levels of arousal and attention, or other nonsensory signals directly related to behavioral performance . For exaNetwork states provide a rich experimental variable, which can explain a multitude of neuronal response properties. In rodents, sensory responses have been found to be noticeably shaped by the dominant network activity pattern . SpecifiNetwork states can be electrophysiologically measured and are highly correlated with changes in pupil diameter , since bPhysiologically, the correlation of pupil diameter with heart rate and galvanic skin reflex  indicateIn cognitive neuroscience, pupil diameter has additionally been reported to correlate with mental effort in decision-making tasks , as wellIn this review, we propose that using pupillometry measures as an index for network state fluctuations in humans may be a useful approach to explain unaccounted variance in macroscopic neural and behavioral signals.Alternating states of excitability in the waking brain have first been observed in intracellular and local field potential (LFP) recordings of awake rodents. They show large low-frequency fluctuations during periods of quiet resting . The iniThe mentioned network substates, synchronized versus desynchronized activity, can only directly be revealed by invasive readouts reflecting synaptic activity , action potentials , or membrane potentials (whole-cell recordings). The recent introduction of pupil diameter as a reliable peripheral marker for network state fluctuations ,b would As neuronal activity patterns can be highly conserved across species  and the Neuromodulatory pathways, especially the central cholinergic and noradrenergic pathways, have been shown to be directly involved in shifts of ongoing cortical activity and network responsiveness . ImportaLC activation is robustly associated with pupil dilation dynamics. Indeed, LC firing reliably anticipates spontaneously occurring, or stimulus-triggered, changes in pupil diameter . LikewisThe inverted-U relationship between arousal and performance  proposed by The inverted-U relationship was confirmed between task performance in a go/no-go task and neuronal activity in the mouse auditory cortex . MoreoveThus, variations in the arousal of awake human subjects contain an optimal zone for neuronal and behavioral responses which can be determined by tracking cortical state fluctuations either directly, through electrophysiological recordings, or indirectly, by using pupil dilation measurements. Moreover, network states have been shown to influence sensory processing efficiency and response times and might further extend to higher-order effects on learning and memory-related tasks.Concerning stimulus-response properties, during the desynchronized state, mouse barrel cortex neurons show a lower stimulus detection threshold, higher response fidelity, and shorter response latency . In audiSince human behavioral response timing is highly variable from trial to trial, including the timing of neuronal activity as a variable would be helpful to explain this variability. Tracking neuronal population activity across the human cortex demonstrated how variations in the timing of neural activity relate to variations in the timing of behavior in a modified Posner visual-attention cueing task . WhereasPutting these previous findings into perspective regarding underlying neural activity, it seems worthwhile exploring such datasets while employing pupil diameter as a direct measure for network state. As there is already work showing the influence of network state on basic behavioral response probabilities and preliminary evidence for a role in higher cognitive function, we propose to explore the influences of network state indexed by pupil dilation on cognitive and decision-making tasks.Pupil diameter has been used as a proxy measure for arousal in effortful decision-making tasks . ChangesAlthough it has been proposed that changes in network state interact with biased decision making in the face of uncertainty , the relpost hoc, dedicated analyses, help explain previously unaccounted variance in decision-making studies. Hence, this approach could provide a novel, neurophysiologically defined technique of exploring the underpinnings of everyday choices.As explained above, pupil dilation has routinely been measured in decision-making studies and was also related to cognitive variables, such as arousal, and to neuromodulatory fluctuations. However, the finding of pupil dilation directly reflecting underlying excitatory states of the neural network opens another dimension of explanatory value. Introducing a network-state related variable and separating behavioral and neural data based on pupil dilation measures would, through Considering the well-established physiologic evidence outlined above, internal brain dynamics which have previously been shown to underlie neuronal responses may similarly influence high-level cognition, decision-making outcomes and learning. This influence on high-level brain functions has already been explored in rodents and primates , the timFirst steps in the exploration of learning dynamics regulated by pupil-linked arousal systems have already been made: brief changes in pupil dilation predicted the reliability of responses in a predictive inference task . These aEstablishing a link between spontaneous network fluctuations, pupil diameter, and behavioral performance is achievable in experiments recording whole-brain activity. Macroscopic measures  can be related to pupillometry, and to behavioral performance, learning, or decision-making outcomes.It is well established that pupil diameter fluctuates in response to changes in environmental luminance. Thus, the first step in any study aiming to record meaningful pupillometry data are to ensure that all visual stimulation is isoluminant and no sudden transitions in visual stimulation are included in the experimental paradigm, since these may induce pupillary responses triggered by visual novelty. Additionally, subjects should be screened for preserved central and peripheral innervation to pupil muscles .The recording of pupillometry is achieved noninvasively by camera-based, infrared eyetrackers. Commercial alternatives are matched by open-source systems, which in some cases include their own analysis software  making tThe recorded pupillometry datasets can be sorted offline for sustained dilation or constriction periods, indicative of desynchronized (“active”) and synchronized (“resting”) network states respectively. Here, exact thresholds for pupil dilation, microdilation and constriction remain to be established, but tracking the first derivative of pupil area would allow for detection of rapid changes based on the signal's slope. Once sorted, the data  recorded during putative desynchronized or synchronized states can be analyzed accordingly and response times or learning and decision-making parameters can be compared between states. Specific data analysis techniques which would be appropriate include linear regression or representational similarity analysis , among aWe encourage employing pupillometry as a noninvasive, robust proxy measure of ongoing network states and highlight the need to verify the corresponding predictions derived from animal models in humans.Fluctuations between cortical states occur constantly and frequently throughout awake periods . These cInvestigating the direct interrelation of underlying global EEG, MEG, or fMRI activity reflecting fluctuations of brain state and pupil diameter changes, and relating both measures to behavioral performance, learning and decision making, would put previous findings into perspective, eventually demonstrating a dependency of higher-order cognitive operations on internally generated states of the brain. Spontaneous fluctuations of ongoing neuronal activity likely influence behavioral outcomes and learning, but can equally be altered by environmental stimulation, and thus represent an important mediator variable which should be considered in a broad range of neurophysiological measurements. The possibility to track these state changes within human cognitive experiments by pupil dilation measures could greatly enhance the current knowledge about the dependency of human decision-making processes on neural network states.The work reviewed here suggests a direct relationship of changes in pupil diameter and cortical state fluctuations in the awake brain. As discussed above, pupil diameter has been commonly associated with psychological constructs, notably arousal and cognitive effort, where a consistent relationship with NA neurons in LC has gained ample empirical support. However, until recently, the close, phase-locked relationship with brain state reflected by membrane and local LFPs was not known. The question remains whether pupil dilation also proves as a reliable biomarker for the described substates of wakefulness in human subjects, and whether it can be used to predict neuronal responses, task performance and learning, beyond sensory perception paradigms. It is plausible that results in humans will follow those in animal models, given how conserved state variations are across mammalian brains . Ultimat


Duchenne Muscular Dystrophy is a rare and fatal neuromuscular disease in which the absence of dystrophin from the muscle membrane induces a secondary loss of neuronal nitric oxide synthase and the muscles capacity for endogenous nitric oxide synthesis. Since nitric oxide is a potent regulator of skeletal muscle metabolism, mass, function and regeneration, the loss of nitric oxide bioavailability is likely a key contributor to the chronic pathological wasting evident in Duchenne Muscular Dystrophy. As such, various therapeutic interventions to re-establish either the neuronal nitric oxide synthase protein deficit or the consequential loss of nitric oxide synthesis and bioavailability have been investigated in both animal models of Duchenne Muscular Dystrophy and in human clinical trials. Notably, the efficacy of these interventions are varied and not always translatable from animal model to human patients, highlighting a complex interplay of factors which determine the downstream modulatory effects of nitric oxide. We review these studies herein. As the disease progresses, and damage and degeneration accrues, the regenerative capacity of the muscle diminishes and becomes unable to match the demand for repair , and that nitrate supplementation can elicit positive physiological responses in diseased tissue, investigating such a therapy for DMD is rational.The benefits of nitrate supplementation also extend to disease states. In chronic obstructive pulmonary disease patients, acute beetroot juice supplementation improved exercise capacity and decreased blood pressure , 105. Simdx mouse and its downstream effects on muscle metabolism and architecture [mdx mouse through the restoration of NO availability. As metabolic dysfunction and insufficiency is a dominant feature of dystrophin-deficient muscle, we investigated two metabolic pathways that can be mediated by NO — glucose uptake and mitochondrial function. We demonstrated normal basal- and contraction-induced glucose uptake in mdx muscles, which is consistent with previous reports of normal insulin-dependent glucose uptake (which is NO-independent) in dystrophin-deficient muscle [To date, we are the only group to have investigated nitrate supplementation in the itecture . Previouitecture , suggestt muscle . Howevert muscle  and othet muscle , 111. Int muscle . Thus, nmdx mice that we did observe was reduced hydrogen peroxide generation, indicating reduced oxidative stress at the mitochondrial level [One benefit of nitrate supplementation in al level . Outrighal level . Our final level , 114, hiOne clinical trial has also investigated sodium nitrate therapy in BMD patients. In this study, an acute single oral nitrate dose (140 mL beetroot juice concentrate containing 8.4 mmol inorganic nitrate) was shown to improve functional sympatholysis and post-exercise hyperaemia in ambulatory BMD patients . While wNO plays an important role in a variety of biological processes and in dystrophin-deficient muscle where NO production is limited due to the secondary reduction of nNOS, it is likely a significant contributor to disease progression. While improvements in muscle function, architecture and metabolism have been demonstrated using various methods to increase NO bioavailability including restoration of the nNOS protein, ˪-arginine supplementation and PDE inhibition, there are also limitations and/or side effects that need to be addressed. This is particularly true since the beneficial effects observed in pre-clinical animal models of DMD have largely failed to translate to clinical improvements in DMD patients. In the one ʟ-arginine supplementation study that has successfully translated in a clinical human DMD pilot trial, these patients were notably steroid naïve, and thus not receiving SoC treatment. These data highlight important drug/functional interactions that clearly require further elucidation. There are also variations in the outcomes at the muscle fibre level with different models of NO induction. For example, beneficial effects have been observed with NO donors, typically in addition with anti-inflammatories or which have additional alternate functions at the muscle level , but not with nitrate supplementation. Moreover, it appears that chronic manipulation of the nitrate-nitrite-NO pathway may not be a viable therapeutic option for DMD given its tendency to promote damage and further dystropathology. While we are currently the only group to have investigated nitrate supplementation as a therapy for DMD, our findings suggest that long-term/chronic nitrate supplementation is detrimental to dystrophin-deficient muscle and may require a concomitant increase in nNOS protein expression to impart the same benefits it does in healthy muscle. This idea is supported by the beneficial effects seen in BMD patients following acute sodium nitrate supplementation, who express low, yet detectable, levels of both dystrophin and nNOS. However, further investigation is required to fully elucidate this intimate relationship. Targeting NO delivery to skeletal muscle with the concomitant induction of nNOS protein expression, appears to be a logical future direction in the utilisation of NO donation as a therapy for DMD. The translational capacity of this research however must address nNOS therapies in conjunction with SoC , as this research is currently lacking in pre-clinical animal models.


The production of transgenic farm animals  via genome engineering for the gain or loss of gene functions is an important undertaking. In the initial stages of genome engineering, DNA micro-injection into one-cell stage embryos (zygotes) followed by embryo transfer into a recipient was performed because of the ease of the procedure. However, as this approach resulted in severe mosaicism and has a low efficiency, it is not typically employed in the cattle as priority, unlike in mice. To overcome the above issue with micro-injection in cattle, somatic cell nuclear transfer (SCNT) was introduced and successfully used to produce cloned livestock. The application of SCNT for the production of transgenic livestock represents a significant advancement, but its development speed is relatively slow because of abnormal reprogramming and low gene targeting efficiency. Recent genome editing technologies  have been rapidly adapted for applications in cattle and great results have been achieved in several fields such as disease models and bioreactors. In the future, genome engineering technologies will accelerate our understanding of genetic traits in bovine and will be readily adapted for bio-medical applications in cattle. Livestock are very important to humans because they provide food resources (meat and/or milk) and other by-products such as leather. Cattle are known as the best animals for producing large amounts of milk and/or meat and are regarded as a valuable protein resource. Additionally, they are utilized for research regarding assisted reproduction technologies such as in vitro fertilization, superovulation, embryo transfer, somatic cell nuclear transfer (SCNT) and cryopreservation, which help us to further our understanding of basic and advanced embryology in animals as well as in humans. Recently, the introduction of new genome technologies such as whole genome sequencing and genome manipulation in cattle, have opened a new era for industrial applications. In this review, we will summarize several genomic engineering technologies for producing genome modified cattle (GMC).GMC production has progressed relatively slowly for livestock Fig.  1–3]. I–3. I1–3]As an alternative to micro-injection with plasmid DNAs, high integration of a targeted foreign gene to produce GMC using a viral gene delivery system was introduced Fig.  5], and, and5], As an complementary procedure to micro-injection of the target DNAs or virus-infection, SCNT has been employed, in which a somatic cell, is injected into the enucleated oocytes, then fused, activated, and cultured in vitro up to blastocysts  Fig. 3)3). ScienDue to several disadvantages  as previously discussed, the injection of simple plasmid DNAs into zygotes has not to be chosen for producing GMC as priority. One of the complementary options for the introduction of simple plasmid DNAs into GMC could be the DNA transposon system, because this system improves the occurrence of mosaicism and transgene integration Fig. . Indeed,The DNA transposon system is known as an efficient method for delivering foreign DNA into the host genome. Among the known transposon systems, SB and PB are primarily used for producing rodents with integrated target genes , 13. TheTransposon systems, where the utilization of transposon-transgenic donor cells for bovine SCNT and the production of transgenic blastocysts has been demonstrated , 15, intCurrently, the production of transposon-based transgenic cattle utilizes ubiquitous expression of the integrated elements. In the future, tissue-specific or conditional expression  is needeThe reason that research regarding genome modified mice has advanced is due to the isolation of germline transmitted embryonic stem cells, which have pluripotency. Mouse embryonic stem cells combined with homologous recombination and transgene integration have played an important role in the production of many disease or genetic mouse models –23. HowePreviously, we described how to integrate and express exogenous genes. Genome editing for endogenous genes in GMC will be reviewed in this section. Homologous recombination (HR) has been used to knockout the target region of the endogenous genome in cattle before the introduction of genome editing technologies such as Zinc Finger Nuclease (ZFN), Transcription activator-like effector nuclease (TALEN), and Clustered regularly interspaced short palindromic repeats (CRISPR)-Cas9. In mice, embryonic stem cells using HR are screened and single colony-derived cells are employed for chimerism or blastocyst complementation. However, due to the absence of embryonic stem cells in livestock, the frequency of HR events in cattle is very low. Furthermore, due to their limited life span, long-term culture of somatic cells for screening knockout-single cell colony SCNT exhibit a low efficiency in cattle Fig. . As a reGenome editing technologies have recently been highlighted in many organisms . ZFN andWe believe genome editing technologies will be applied to three areas. First, the technologies will be used for basic or disease related gene function research in cattle. As previously reported, disease-related gene edited cattle have already been produced. A study reported the birth of tuberculosis-resistant cattle produced via TALEN . The samThe second area where genome editing technologies will be applied is the application of these technologies to improve genetic traits. Bovine genome sequencing revealed characteristic traits in proved bulls and traits introduced via random mutation and natural selection, such as increased muscle (myostatin gene mutation) or dehorning, were identified at the genome level. Mutated myostatin and dehorned cattle have already been born and grown into adults with the expected phenotypes  , 40. DehThe third area where genome editing technologies will be applied, is in the production of designed milk or bio-pharmacological proteins can be manufactured in genome edited cattle , 43. BecThe topic of off-target effects should be addressed in regard to genome editing technologies that generate live GMC. When a target locus was selected and designed for ZFN, TALEN, and CRISPR-Cas9, unwanted mutations have occurred at non-target loci –49. Therhttp://www.fda.gov/downloads/AnimalVeterinary/SafetyHealth/AnimalCloning/UCM124756.pdf), but not in the EU [The scientific technologies for genome editing have developed rapidly over time. However, national policies and consensus on these technologies have not caught up with current trends and there is a difference in the policies surrounding this topic in different countries. For example, SCNT-derived cattle, goats, and pigs are accepted as food in the USA . The production of gene-edited livestock is gradually increasing, and we think that it is necessary to address its’ scientific safety and efficacy. Additionally, here is also a need to promote rational regulations to guide the commercial and scientific use of GMC.Recently, genome engineered fish  were the first transgenic animal to receive approval as a food source in the USA and Canada , 53. AddGenome engineering technologies have been rapidly applied adopted for producing GMC because they have powerful advantages in the cattle industry. In the future, if policy and technological advances become harmonious, GMC will contribute to humanity and animal welfare in terms of genetic traits, disease resistance and understanding, and protein (bioreactors) production.


Danaus plexippus) population in North America has sharply declined over the last two decades. Despite rising concern over the monarch butterfly's status, no comprehensive study of the factors driving this decline has been conducted. Using partial least-squares regressions and time-series analysis, we investigated climatic and habitat-related factors influencing monarch population size from 1993 to 2014. Potential threats included climatic factors, habitat loss (milkweed and overwinter forest), disease and agricultural insecticide use (neonicotinoids). While climatic factors, principally breeding season temperature, were important determinants of annual variation in abundance, our results indicated strong negative relationships between population size and habitat loss variables, principally glyphosate use, but also weaker negative effects from the loss of overwinter forest and breeding season use of neonicotinoids. Further declines in population size because of glyphosate application are not expected. Thus, if remaining threats to habitat are mitigated we expect climate-induced stochastic variation of the eastern migratory population of monarch butterfly around a relatively stationary population size.The monarch butterfly ( Totaet al. [et al. [After controlling for the long-term decline in monarch butterfly abundance, we found, similar to other studies, that annual monarch population dynamics were strongly influenced by climatic factors –20,24. SX-space (predictor variables), the explained variation in the Y-space (response variable), and the conjoint variation of the X- and Y-spaces (predictor and response variables). Despite the strengths of the partial least-squares approach, there are still uncertainties remaining that we cannot overcome with the data at hand. For instance, our ability to predict change in population size from one year to the next is hampered by noisy, collinear variables. Glyphosate application  obviated the need for previous year's abundance, derogating the role density dependence plays at the scale of our study. Additional data may increase the differentiability of the other collinear variables in the future.Ecological processes are often extremely complex and, as a result, it can be difficult to discern putative cause-and-effect relations when there are many more predictor variables than there are samples. Small sample sizes preclude complex model development using traditional regression techniques and many environmental covariates associated with biotic responses often covary. The partial least-squares regression approach we took simultaneously maximizes the explained variation in the Our analysis suggests that immediate steps to mitigate the large declines in milkweed due to the use of herbicide-resistant crops in the breeding region is a key strategy for monarch restoration ,14,78. TGiven that ≥92% of corn and soy agriculture in the northern USA is now glyphosate-tolerant , we migh5.We began our threats assessment with three times as many variables as years in our time series of monarch butterfly population size. Partial least-squares regression focused our attention on a subset of the 76 variables, leading to a single best model comprised of three covariates  explaining greater than 90% of the annual variation in abundance. A structural equation model implicates the loss of milkweed as the mechanism by which glyphosate application influences monarch butterfly population size. To offset this loss of milkweed, we suggest that a strategy of restoring habitat in a variety of areas including CRP lands, public and private lands, roadsides and marginal agricultural areas, as well as protecting habitat where monarchs overwinter, would help increase monarch populations  and ther


Compliant flooring aims to prevent fall-related injuries among high-risk olderadults in long-term care, but uptake of compliant flooring in this setting islimited. We hosted a one-day stakeholder symposium to identify advantages anddisadvantages of implementing compliant flooring in long-term care and the mostpressing directions for future research from the perspective of keystakeholders. Twenty-three stakeholders representing health care, industry, andresearch attended the symposium. Attendees believed the most importantadvantages of compliant flooring were reducing injuries in residents who havefallen, potential benefits to care staff, and potential increases in quality oflife for residents. Attendees perceived the most significant disadvantages ofcompliant flooring were financial considerations, lack of research evidence, andchallenges with installation. Attendees indicated a need for additional researchon cost-effectiveness and clinical effectiveness. While stakeholders perceivedcompliant flooring to add value to long-term care, there are significantinformational and financial barriers to uptake. Falls and fall-related injuries among older adults are common and costly. Approximately30 per cent of community-dwelling adults aged 65 years and older will fall each yearwith 10-15 per cent of these falls resulting in serious injury  in September 2016. We recruited attendees, from ourexisting professional networks, to represent a broad audience of stakeholdersfrom health care , industry, and research. We invitedclinicians, allied health practitioners, researchers, interior designers,industry partners, health managers, and regulators. Attendees were not requiredto have any background knowledge or experience with compliant flooring.The day began with a keynote address presented by an international expert inprevention of injury and disease. The talk focused on the use of environmentalinterventions to improve older adults’ mobility and functional independence, andprevent fall-related injuries. Following the keynote, content experts led aseries of podium presentations to disseminate up-to-date evidence aboutcompliant flooring on the following topics: (1) how compliant flooring works,including an overview of the mechanics; (2) the current available evidencerelated to compliant flooring, based on results from a scoping review; (3) thepush forces required to use floor-based lifts over compliant flooring, based onresults from an ergonomic evaluation; and (4) the perceived feasibility ofcompliant flooring from the perspectives of LTC senior management, based onresults from an interview study. Each presentation was followed by a facilitatedquestion and answer period.Following the podium presentations, we led an interactive workshop to identifyadvantages and disadvantages of implementing compliant flooring in LTC, and toidentify gaps in the available evidence and directions for future research aboutcompliant flooring, from the perspectives of the symposium attendees. Allattendees were invited to participate in the workshop and were considered equalcontributors in all discussions. Attendees were classified based on theiroccupation into four broad stakeholder sub-groups: LTC management ; clinical ; health authority ; andresearch and industry . Our intention was to provide an opportunity for relatedstakeholders to work together and to provide an environment where attendeeswould feel comfortable participating in the table discussions. Each table wasset up to have five to six attendees and was moderated by a workshop facilitatorto ensure everyone contributed. Workshop facilitators were trained to ask threekey questions about compliant flooring in the LTC setting: (1) What do youbelieve are the advantages of having compliant flooring? (2) What do you believeare the potential disadvantages (main concerns) for implementing compliantflooring? (3) What other information would be useful to you ?To help ensure that everyone contributed to the session, attendees were asked torecord their answers to each question on sticky notes, from their ownperspectives and experiences based on their job position. Attendees wereencouraged to write down as many advantages, disadvantages, and gaps as theycould (∼5 minutes per topic). All attendees received handouts of the podiumpresentation slides and a plain-language summary of the existing compliantflooring evidence; they could refer to these materials as they worked. Thesticky notes for each of the three topics were collected by the facilitator anddisplayed and organized by theme on a poster board so that the group could allsee. Each group then collectively ranked their top three advantages,disadvantages, and gaps, and one attendee from each table presented theirgroup’s top three selections to all attendees as part of a closing discussionsection of the workshop. All sticky notes from the workshop session wereretained; each group had different colour sticky notes so we could lateridentify which concepts came from each group. We concluded the day by havingattendees complete an event evaluation form.We collected data before the symposium, during the workshop portion of thesymposium, and at the end of the symposium. Leading up to the symposium, weemailed all attendees to obtain demographic information using a pre-event form(see online supplementary file #1). We asked attendees to indicate their jobtitle, place of work, how their job or place of work is involved in preventinginjuries among older adults, and why they chose to attend the symposium. Duringthe symposium, we retained all sticky notes from the workshop and also recordedeach group’s top three selections of advantages, disadvantages, and researchgaps. At the end of the symposium we asked each attendee to complete a two-pagepost-event evaluation form (see online supplementary file #2), informed byWathen, Sibbald, Jack, and Macmillan . This seWe used JMP 12.0.1 software (SAS Institute) to calculate all descriptivestatistics from the pre-event and post-event forms and NVivo 11.2.2 software to code and manage all long-form data obtained from thepre-symposium data collection, workshop, and event evaluation form.n = 209).The analyst then refined these codes to form themes and subthemes that were usedto develop a thematic framework  and 70.0 per centwere women (n = 16). Attendees primarily represented LTC, regional health authorities , research , industry, and acute care (n = 20) or Ontario .Twenty-three stakeholders attended the symposium. Of these attendees, 23 (100%)completed the pre-event form, 23 (100%) attended the morning keynote and podiumpresentations, 17 (73.9%) attended the afternoon workshop, and 21 (91.3%)completed the post-event form. Six attendees were unable to attend the afternoonworkshop because of work demands. Attendees had a mean age of 50.4 years. Some atThree main themes – advantages, disadvantages, and research gaps – each with fivesubthemes, emerged from the workshop data .Table 3:Attendees identified several potential advantages associated with implementingcompliant flooring in LTC .AttendeFor the injury reduction subtheme, attendees highlighted that compliant flooringmay reduce both the number and severity of fall-related injuries should a falloccur, including serious injuries like hip fractures and head injuries.Attendees believed compliant flooring may be superior to other injury preventionintervention strategies, such as hip protectors, as it has the ability to reduceinjuries for any body part that impacts the ground by providing high forceattenuation. Attendees also affirmed that compliant flooring enables theenvironment to be safer for all residents and may also reduce injuries fromfalls sustained by LTC staff and families and friends of the LTC residents whovisit the care home.Attendees perceived that compliant flooring may provide important benefits tocare staff. If residents have fewer fall-related injuries following theimplementation of compliant flooring, staff will likely experience reducedstress and workload , and will have more time to focus their energy onother quality issues. Attendees mentioned that compliant flooring may alsoreduce fatigue of the care staff when walking or standing on the flooring.Attendees suggested that compliant flooring may also help to stimulate thefurther development and use of technology  tocompensate for the increased forces required for care staff to maneuverequipment over compliant flooring. This is further described in the perceiveddisadvantages section below.Symposium attendees also suggested that compliant flooring may improve thequality of life for residents. They stated this may occur, in part, as a directdownstream effect of injury reduction. Attendees also remarked that by havingcompliant flooring installed in LTC, residents (and their family members) mayhave an improved sense of security and safety, and residents may in turnincrease their mobility and activity levels throughout the care home. Thus,residents may experience a decreased fear of falling and increased physicalactivity levels and independence. The group also suggested that compliantflooring may improve resident autonomy by replacing other interventions thatresidents and staff may not want to use .Coinciding with a reduction in fall-related injuries, attendees discussed theimportant role that compliant flooring might play in reducing overall healthcare costs. This is based on the assumption that by reducing the number ofserious injuries sustained by the residents, there will be a reduced number ofhospital transfers and admissions, resulting in a reduction in health caredollars spent on fall-related injuries. In addition, if compliant flooring isfound to reduce injuries, attendees proposed that care homes with compliantflooring may be viewed as more desirable by the public; one means of achievingthis could be using this flooring as a marketing tool by advertising the site asan innovative and proactive care home.Attendees identified several potential disadvantages of implementing compliantflooring in LTC, classified into five subthemes. The biggest perceiveddisadvantages were financial considerations, lack of research evidence, andchallenges with installation . Ofslightly less importance, although still of concern, were negative repercussionsinvolving staff and general concerns about flooring performance.Attendees ranked cost as the number one disadvantage associated with compliantflooring. Cost was described in a multitude of ways, including the cost of thematerial itself (relative to standard flooring), installation, maintenance, andadditional equipment costs  to account for the differences inflooring stiffness versus standard flooring. Attendees were also concerned withwho would provide the LTC care sites with the funding and how the costs of theflooring could be justified.Collectively, attendees believed that the lack of research was a disadvantage.Attendees believed that more research needs to be performed before consideringwidespread implementation of compliant flooring in LTC. Specific examples ofperceived unknowns include effects on balance, long-term utility , and clinical effectiveness.The attendees remarked that installing compliant flooring in an existing carehome could present significant challenges. It would be disruptive for residentsand staff. If a care home decided to renovate only a portion of the total floorsurface, the need would arise for installation of transitional ramps to accountfor height differences between the standard flooring and the compliant flooringsystem. Some of the attendees commented from personal experiences that thesetransitional areas can make it more difficult for residents to walk (with andwithout mobility aides) and may increase the risk of tripping for both residentsand staff.The attendees voiced concern that the implementation of compliant flooring in LTCmay have potential repercussions for care staff. Specifically, they were awarethat a floor with a lower stiffness would increase the rolling load resistancewhen care staff push or pull equipment and would possibly increase the risk ofcare staff sustaining musculoskeletal injuries. In addition, attendees wereuncertain if all staff would want to adopt this type of injury preventionstrategy.Attendees also brought up general concerns about flooring performance. Namely,attendees were apprehensive about its durability, maintenance requirements, andsustainability in comparison to standard flooring. In addition, attendeesacknowledged that the flooring will only have the ability to protect body partsthat impact the floor, and not body parts that may impact a wall or furniturebefore impacting the ground.Attendees indicated they still had uncertainties about cost-effectiveness,clinical effectiveness, biomechanical efficacy, flooring performance, andworkplace safety of compliant flooring. The need for additional knowledge oncost-effectiveness and clinical effectiveness received the most emphasis.A commonly discussed topic during the workshop was the lack of available evidencerelated to the cost-effectiveness of compliant flooring. Attendees indicatedthey would like additional cost-benefit and/or cost-effectiveness analysesperformed to help determine whether compliant flooring should be installed inLTC. Attendees suggested that future economic analyses should include potentialcost savings resulting from prevention of other injuries in addition to hipfractures , since most cost analyses havebeen performed by considering only hip fractures Lange, . Other iAttendees suggested the need, second to cost-effectiveness, for more research todetermine the intervention’s clinical effectiveness in the form of longer (induration) and/or larger (number of participants) randomized controlled trials.Attendees stated they would like to see more results from trials conducted withthe population of interest  and multiple types ofinjuries . Attendeesalso mentioned that it would be worthwhile to determine whether certainenvironments  or populations would benefit more from compliantflooring than others. Attendees were also curious about whether compliantflooring would increase mobility and activity levels, decrease fear of falling,or increase the incidence of falls in LTC residents.Attendees were interested to know more about the effects of compliant flooring ondynamic balance tasks and gait performance, including individuals that may haveneurological deficiencies . Attendees also were interested inassociations between compliant flooring and point loading  andnon-vertical forces .Furthermore, attendees also suggested there is an evidence gap on what types ofequipment should be modified to ensure that the care staff are able to worksafely over compliant flooring. Attendees mentioned the need to directly measurewhether there is an increase in workplace injuries after installation ofcompliant flooring. They also discussed the need for manufacturers to optimizethe “dual stiffness” characteristics of the flooring so that it is soft enoughto reduce falls but rigid enough to not impair walking. Finally, attendees hadgeneral uncertainties about durability, hygienic properties, effect on theenvironment, and sustainability of available compliant flooring systems.SD = 0.7] points from afive-point scale), benefit of meeting colleagues and exchanging informationabout compliant flooring (4.7 [0.5] points), level of comprehension of thematerial presented (4.8 [0.4] points), overall quality of discussion anddialogue at the symposium (4.9 [0.4] points), and overall satisfaction with thesymposium . Of these, 95.2 per cent (n = 20)stated they plan to share what they learned with others, and 42.9 per cent(n = 9) planned to change their behaviour.The majority of attendees ranked the symposium high in terms of its relevance totheir current work .When considering the drawbacks, financial considerations were ranked by attendees asthe number one disadvantage. It has been previously documented that compliantflooring costs more than standard flooring . Thisdemonstrates the need for more clinical trials to provide additional evidence aboutcompliant flooring. Attendees also felt that future research should considerexamining dynamic balance and gait performance over compliant flooring among endusers as a lot of previous research was performed with young, healthy participants relevance to their current work, (2) meeting colleagues andexchanging information, (3) ease of understanding material presented, and (4) thequality of discussion and dialogue during the symposium.We used a novel approach to explore the perceptions of key stakeholders aboutimplementing compliant flooring in LTC. Although we included stakeholders fromdifferent professional backgrounds, some groups  were betterrepresented than others . Attendees were invited from ourexisting networks in British Columbia and Ontario and, therefore, may have haddifferent perceptions than those from other regions of the country, and may nothave held the same views as stakeholders in similar roles from other countries.Moreover, the symposium did not directly address the perspectives of LTCresidents and their families, an important stakeholder group for the successfulimplementation of compliant flooring in LTC. Future research would benefit frompartnering with these groups. Though our sample size afforded meaningfulengagement from all attendees during the workshop, it precluded the ability tostratify the results by subgroup. Finally, our approach focused on implementingcompliant flooring within LTC. Therefore, the results may not translate directlyto other settings, such as the community or acute care, though similar methodscould be used to explore advantages, disadvantages, and research gaps in thosesettings.In conclusion, attendees identified key advantages and disadvantages of implementingcompliant flooring, as well as important gaps in evidence about compliant flooringthat should be prioritized by future studies. By attending the workshop, attendeesgained awareness about compliant flooring systems for preventing fall-relatedinjuries among residents and an understanding of the evidence supporting its use asa technology to prevent fall-related injuries. We anticipate that the results ofthis symposium will facilitate future research projects to expand knowledge oncompliant flooring for injury prevention.For supplementary material accompanying this paper visit http://dx.doi.org/10.1017/S0714980817000551.click here to view supplementary material


SCN5A, which encodes for the cardiac Na+ channel. To date, variants in 19 genes have been implicated in this condition, with 11, 5, 3, and 1 genes affecting the Na+, K+, Ca2+, and funny currents, respectively. Diagnosis of BrS is based on ECG criteria of coved- or saddle-shaped ST segment elevation and/or T-wave inversion with or without drug challenge. Three hypotheses based on abnormal depolarization, abnormal repolarization, and current-load-mismatch have been put forward to explain the electrophysiological mechanisms responsible for BrS. Evidence from computational modeling, pre-clinical, and clinical studies illustrates that molecular abnormalities found in BrS lead to alterations in excitation wavelength (λ), which ultimately elevates arrhythmic risk. A major challenge for clinicians in managing this condition is the difficulty in predicting the subset of patients who will suffer from life-threatening VT/VF. Several repolarization risk markers have been used thus far, but these neglect the contributions of conduction abnormalities in the form of slowing and dispersion. Indices incorporating both repolarization and conduction and based on the concept of λ have recently been proposed. These may have better predictive values than the existing markers.Brugada syndrome (BrS), is a primary electrical disorder predisposing affected individuals to sudden cardiac death via the development of ventricular tachycardia and fibrillation (VT/VF). Originally, BrS was linked to mutations in the  Although SCN5A is the commonest affected gene, its mutations are only implicated in approximately a fifth of patients. In some pedigrees, affected members did not have mutations in this gene  pattern of a coved-shaped ST segment elevation (STE) ≥2 mm and negative T-wave in the right precordial leads with or without drug challenge using a class I anti-arrhythmic agent such as flecainide  and one or two β subunits . Loss-of-function mutations in Scn5a have been associated with BrS  protein  responsible for Ito  determining IK, ATP  have also been implicated in BrS , Scn5a1798insD/+ and SCN5aG1408R mice demonstrate reduced CV associated with interstitial fibrosis  of the APs are responsible for arrhythmogenesis. The seminal work by Martini and colleagues found that patients suffering from RBBB and ST segment elevation also had fibrosis of the right ventricle and the conduction system  compared to the endocardium with low Ito. Therefore, epicardial APs, but not endocardial APs, lose their dome shape morphology. During phase 1 of the AP, the outward shift of ionic current balance leads to failure of LTCC activation, which also contributes to the loss of the AP dome. Originally, phase 2 reentry was hypothesized to involve electrotonic coupling between these cardiac regions, which permits propagation of the AP dome from endocardial regions where it is maintained to epicardial regions where it is abolished, thereby producing an extrasystole (Yan and Antzelevitch, The repolarization theory states that differential APD shortening across the myocardial wall is primarily responsible for the BrS phenotype. Loss-of-function Scn5a mutations can have opposing effects on the fast and slow inactivation of Napeak − Tend, a marker of global dispersion of repolarization, have been found in BrS patients compared to healthy subjects (Morita et al., ICa is reduced or IK is increased, abnormal repolarization is likely to be important in generating or sustaining VT/VF. Indeed, subjects with loss-of-function Ca2+ channel mutations have shortened QT intervals, which may support arrhythmias by a reentrant mechanism (Antzelevitch et al., However, the above data from wedge preparations on abnormal repolarization must be recognized with some caution, as no significant transmural differences in repolarization durations were found in the clinical setting (Coronel et al., Abnormal restitution has long been recognized as a key determinant of arrhythmogenicity in arrhythmic disorders such as long QT and Brugada syndromes (Nishii et al., However, restitution analysis alone underestimates the extent of APD alternans (Matthews et al., Ito or increased ICa could compensate for the reduced sodium current, in turn reducing the degree of ST segment elevation. Such preclinical findings are consistent with human data (Hoogendijk et al., A third mechanism involves current-to-load mismatch in the right ventricle (Hoogendijk et al., In patients with Brugada syndrome, structural abnormalities are indeed observed in the RV and RVOT, which would increase current-load mismatch and excitation failure (Coronel et al., In conclusion, an increasing number of genes have been implicated in the pathogenesis of BrS. The genotype-phenotype correlation for many of these variants are poorly characterized. The commonest gene affected, SCN5A, is only implicated in approximately a fifth of patients. In some pedigrees, affected members did not have mutations in this gene (Probst et al., GT: Design of manuscript; interpreted primary research papers; drafted and critically revised the manuscript for important intellectual content; creation of figure. VL: Interpreted primary research papers. Critically revised the manuscript for important intellectual content. KL: Interpreted primary research papers; drafted and critically revised the manuscript for important intellectual content. VL: Critically revised the manuscript for important intellectual content. YC: Drafted and critically revised the manuscript for important intellectual content. WK: Drafted and critically revised the manuscript for important intellectual content. RL: Critically revised the manuscript for important intellectual content. BY: Drafted and critically revised the manuscript for important intellectual content.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.


Retinal vein occlusion (RVO) is a common vascular disease of retina; however, the pathomechanism leading to RVO is not yet clear. In general, increasing age, hypertension, arteriosclerosis, diabetes mellitus, dyslipidemia, cardiovascular disorder, and cerebral stroke are systemic risk factors of RVO. However, RVO often occur in the unilateral eye and sometimes develop in young subjects who have no arteriosclerosis. In addition, RVO show different variations on the degrees of severity; some RVO are resolved without any treatment and others develop vision-threatening complications such as macular edema, combined retinal artery occlusion, vitreous hemorrhage, and glaucoma. Clinical conditions leading to RVO are still open to question. In this review, we discuss how to treat RVO in practice by presenting some RVO cases. We also deliver possible pathomechanisms of RVO through our clinical experience and animal experiments. Retinal vein occlusion (RVO) is common vascular disease of retina. Some well-known studies in large populations indicate that RVO is the second most frequent retinal vascular disease behind only diabetic retinopathy and that RVO is the fifth leading cause of blindness –4; howevDespite taking numerous clinical courses of RVO, these complications are decreasing due to the development of various therapeutic approaches in addition to early alert and treatment by internal medicine doctors for cardiovascular diseases like systemic hypertension and dyslipidemia, which are well-known risk factors of RVO , 12–14. Interestingly, the prevalence of RVO in Japan is higher than in other countries , 23–27. Many questions remain regarding the clinical condition leading to RVO even though anti-VEGF therapy can save many RVO patients experiencing deteriorated vision. Why does it often occur unilaterally? Does the mechanical “obstruction” or “compression” of the venous lumen induce RVO? Does the affected vein always become thrombosed in the eye with RVO? If we assume a thrombus exists in the affected vein, why is the blood flow not completely disturbed in fluorescein angiography? Are systemic venous thromboembolic (VTE) diseases, such as deep venous thrombosis and pulmonary embolism, not always associated with RVO? Why is BRVO sometimes resolved by itself? Why do young patients sometimes develop RVO without dyslipidemia? Why is the photoreceptor located at the outer retina impaired by the occlusion of the retinal vein located at the inner retina in patients with RVO-related macular edema? Like anti-VEGF therapy, repeated injections of anti-VEGF agent are generally admitted if patients prefer, but can the disorder of the foveal photoreceptor layer by RVO be recovered with improved visual acuity? These questions and others remain unanswered.In this review, we discuss how to treat patients in practice by presenting some RVO cases. We also deliver possible pathomechanisms of RVO through our clinical experience and animal experiments.Retinal vein occlusion (RVO) is the second most frequent retinal vascular disease behind only diabetic retinopathy, and it is the fifth leading cause of blindness –4. GenerThe prevalence of RVO has been reported by Rogers et al. . They suBoth BRVO and CRVO have the following common points: patients with RVO often have systemic hypertension and/or dyslipidemia as a preexisting disease; they show some findings of superficial or deep retinal hemorrhages, cotton wool spots (CWS), venous dilatation, and venous tortuosity in their ocular fundus; they are divided into ischemic and nonischemic , 42; proThere are also significant differences between BRVO and CRVO. CRVO develop neovascular glaucoma, which lead to the risk of blindness . In caseRecently, various therapeutic approaches have been developed, such as anti-VEGF therapy and the intravitreal implant of steroids . For RVOIn this article, some clinical cases that we experienced are introduced and information on treatment is found in Figures 1In patients with RVO, retinal circulation is delayed. It is also important to evaluate the degree and area of blood flow disturbance by using fluorescein angiography (FA) and/or optical coherence tomography (OCT) angiography.There were many efforts made by researchers and ophthalmologists to evaluate the changes in fundus circulation using FA, indocyanine green angiography (IA), laser Doppler velocimetry, laser speckle flowgraphy, and the Oxymap™ in RVO for years before the developed OCT angiography –78. It iOptic nerve head ocular blood flow did not significantly change before and after the injection of the anti-VEGF agent, but chorioretinal circulation was decreased transiently in most treatment-effective cases of macular edema with RVO Figures  and 7. IDuring our clinical researches for ocular blood flow in patients with RVO , 81, we Recently, the technology of OCT imaging has progressed rapidly, and OCT angiography is a popular tool for evaluating the pathology of RVO. Some papers found out that OCT angiography can visualize microvascular abnormalities equally well or better than FA , 94, andThe pathomechanism leading to RVO is not yet clear. BRVO commonly occurs at the arteriovenous crossing. It is assumed that the diseased artery mechanically compresses the vein. However, it has been reported that the retinal vein seems to run deep under the artery at the crossing in eyes with arterial overcrossing, and the venous lumen often appears to be preserved, even at the arteriovenous crossing, as observed by thin sectioning with optical coherence tomography (OCT) in patients with acute BRVO , 96. In The tortuosity of the vein is one clinical finding in CRVO. Muraoka et al.  reportedIn addition, these interesting new findings may be able to act, leading to CRVO and normal tension glaucoma (NTG). The pathomechanism of NTG is also unknown. Because of this, we retrospectively investigated 234 Japanese CRVO patients over 5 years, with follow-ups of more than 12 months, and evaluated the prevalence of glaucoma . Of the Going back now to RVO and VEGF, the congestion of the vein in RVO can lead to local hypoxia, thereby increasing VEGF, which in turn contributes to macular edema , 105. AnOne possible candidate is endothelin. Endothelin-1 (ET-1) is a potent vasoconstrictor . It reguWith this in mind, we conducted a prospective study to evaluate changes in ET-1 following an injection of intravitreal bevacizumab (IVB), which is the anti-VEGF agent with the longest serum half-life , to deteThe overexpression of VEGF hints at a simultaneous overexpression of ET-1, and, most probably, both VEGF and ET-1 are involved in the pathogenesis of RVO-related macular edema. VEGF is known to stimulate the production of NO, which is an endothelium-derived relaxing factor, and then increases the blood flow, as described in RVO and Ocular Circulation. If the relation among VEGF, NO, and ET-1 became unbalanced in the retina, RVO might occur. It is known that a reduction of VEGF normally also leads to a reduction in ET-1 , 116. HoIn an RVO experiment, ET-1 blockers were found to improve retinal circulation , 118. InRetinal vein occlusion (RVO) is common retinal vascular disease. Anti-VEGF therapy is now the standard treatment and is effective for RVO-related macular edema in most cases. However, RVO have a variety of clinical conditions and its pathomechanism remains unknown. We provided some ways of distinguishing RVO patients in practice and introduced the vasoactivity of the vein itself and the possible involvement of vasoconstrictors such as ET-1 for the pathogenesis of RVO through our clinical studies, some animal experiments, and recent literatures. Treatment of systemic hypertension and correction of dyslipidemia by improving patients' diets are still important to avoid developing both RVO and cardiovascular diseases . Further


Antipsychotics (APs), antidepressants (ADs) and mood stabilizers are essential components in treatment of most psychiatric disorders and in particular in schizophrenia. Unfortunately, among the various compounds which have been developed, lengthy trials are often required before the optimum medication treatment is found, i.e. with most significant symptom alleviation and minimal side effects. Thus, predictive factors would thus be extremely beneficial in clinical practice. The underlying reasons for this large inter-individualvariability in terms of treatment response are not fully understood. Important factors that influence drug dose, response and side effects include age, gender, patient compliance, constellation of symptoms, co-morbidity, and to a large extent genetic factors.Methods follow two strategic concepts, i.e. 1) review of the literature and review of the clinical utility of using genetic information preemptively and 2) results of own studies evaluating treatment outcome in psychiatric care after genetic information  was provided to more than 350 physicians.There is growing consensus among expert that genetic testing to optimize medication treatment in psychiatry meets criteria for clinical utility. However, utility remains restricted to specific gene-drug pairs and multi-gene test require further validation.Our own research has shown that variation in genes involved in the metabolism of psychotropic drugs (pharmacokinetics) and genes encoding drug targets, such as brain receptors (pharmacodynamics) are associated with plasma drug levels, treatment response, and side effects . In addition, our genome-wide analyses have revealed associations with clinical outcome to antipsychotics or antidepressants and markers in neurotrophins, cell-signaling and inflammatory pathways.With respect to our preemptive genetic testing program in more than 10,000 patients, we received supportive responses from physicians who enrolled patients in our study. Notably, while the vast majority of patients reported improvement in patient outcome, only two physicians indicated that their patient’s symptoms has slightly worsened after they had used the pharmacogenetic report to guide treatment.There is emerging evidence that preemptive genetic testing for numerous gene & psychiatric-drug pairs has reached levels for clinical utility which includes validation of analytical and clinical validity. Genetic testing has become readily available but however clinicians and patients are poorly prepared to this new emerging field and proper education is of utmost importance. This presentation will review the level of evidence for ‘actionable’ gene-drug pairs in psychiatry in addition to present novel genomic findings and reports from our ongoing genetic testing experiences.