Dry eye is one of the most common complications occurring after laser-assisted in situ keratomileusis (LASIK), with virtually all patients experiencing some degree of postoperative dry eye symptoms. Enhanced understanding of the pathophysiology and mechanism of dry eye development in addition to preoperative screening of patients who are prone to dry eye is essential for better patient satisfaction and for improving short-term visual outcome postoperatively. This article reviews the latest studies published on LASIK-associated dry eye, including epidemiology, pathophysiology, risk factors, preoperative assessment, and management. Dry eye following laser in situ keratomileusis (LASIK) is the most common problem faced by refractive surgeons, with virtually all patients experiencing some dry eye after surgery, usually transiently . This siMany patients who seek LASIK surgery can not tolerate contact lenses because of a preexisting dry eye syndrome or dry eye syndrome secondary to long-time contact lens use. It is estimated that 30% of the candidates for refractive surgery have dry eye symptoms and that 50% of the patients have clinical signs of dry eyes prior to surgery . ImportaSigns of post-LASIK dry eye include positive staining of the ocular surface, decrease in tear breakup time (TBUT), lower basal tear secretion, positive Schirmer test, and reduced corneal sensitivity , 12, 13.The exact mechanism by which LASIK causes ocular dryness is not clear, but it is known to be multifactorial. Possible mechanisms include decreased trophic influence on the corneal epithelium due to corneal nerve severing, reduced corneal sensation and blink reflex, damage to the limbal goblet cells caused by the pressure of the suction ring, altered tear film stability due to change in corneal curvature, inflammation, and a toxic effect of topical drops . There iEstimates of the incidence of dry eye syndrome after LASIK vary widely, but almost all patients will have transient dry eye during the postoperative period , with thMost corneal nerve fibers are sensory and derived from the ophthalmic branch of the trigeminal nerve. They enter the cornea at the periphery in a radial fashion parallel to the corneal surface and are located mainly in the anterior third of the stroma. Stromal fibers turn at a 90-degree angle and proceed towards the corneal surface, penetrating Bowman's membrane. They are then divided into several smaller nerves, which again turn at a 90-degree angle and continue parallel to the corneal surface, between Bowman's membrane and the basal epithelial cell layer. They then course obliquely into the more superficial epithelial cell layers where they eventually terminate . MaintenAs noted earlier, the mechanism by which LASIK causes dry eye is multifactorial . Flap crReports of punctate epithelial erosions and rose bengal staining with a normal Schirmer test  have led to the identification of a condition called “laser in situ keratomileusis-induced neurotrophic epitheliopathy” (LINE). In this condition, corneal staining is due to diminished neurotrophic factors released from the severed nerves  or from It would appear that two different mechanisms are capable of causing dry eye after LASIK. One is a reduction in Schirmer test results that indicates an aqueous tear deficiency. Another is LINE secondary to a reduction of blinking and a decreased release of neurotrophic factors . TreatmeThe most significant risk factor for developing severe ocular dryness after LASIK surgery is preexisting dry eyes , 13, 45.It is possible that the parameters in the LASIK treatment itself are important in the risk for developing dry eye. For example, suction time and the diameter of the ablation zone affect corneal sensitivity and the incidence and severity of dry eye , 47. A pTHBS1) gene that was found to be associated with postrefractive surgery chronic ocular surface inflammation [A long-term history of wearing contact lenses before LASIK may contribute to delayed recovery in tear secretion and corneal sensitivity after surgery , 50. Othammation .Asian ancestry has a higher prevalence of chronic post-LASIK tear dysfunction and dry eye symptoms; according to one study, 28% of Asian patients suffered from dry eye symptoms compared to 5% among Caucasian patients post-LASIK surgery . ContribThe few studies that tried to determine whether corneal sensation and the post-LASIK dry eye state are affected by hinge characteristics  producedA meta-analysis that aimed to resolve this issue showed that a horizontal-hinge flap causes less loss of sensation than the vertical-hinge flap and that the difference was significant at 3 months postoperatively . The TBUμm) compared to the microkeratome group (131 μm). It should be noted that other investigators could not find any differences between femtosecond laser and mitcrokeratome in terms of corneal sensitivity, Schirmer testing, TBUT, conjunctival and corneal stainings, and subjective symptoms at 1 week and 1, 3, and 6 months postoperatively [The incidence of LASIK-associated dry eye is higher in patients who had LASIK with microkeratome than in patients in whom the surgery was done with the femtosecond laser . The higratively .Prior to surgery, LASIK candidates should be carefully questioned about dry eye symptoms and undergo a detailed evaluation of the external ocular surface . The canCaution is needed when evaluating patients with dry eyes. A trial of dry eye treatment is needed before performing LASIK surgery, and the surgery can be scheduled if patients respond well to treatment . RefractWhen diagnosing a post-LASIK dry eye state, the most important factor is the anamnesis since no single test is sufficient to diagnose dry eye  and signPatients may complain of irritation, foreign body sensation, pain, grittiness, and photophobia. Compromised tear function may induce a disruption of ocular surface integrity, which disturbs clear vision  and causCorneal fluorescein staining is at its peak at 1 week post-LASIK. Many of these patients do not have feelings of discomfort, probably because the flap has sensory denervation . The conIn contrast, other studies showed that parameters indicating dry eye do not change after LASIK, among them corneal staining, tear breakup time, Schirmer test, tear meniscus height, tear thinning time, osmolarity, and topography , 72, 73.Lastly, the blink rate was shown to be decreased at 3 months, 6 months, and 1 year after LASIK. The drive for normal blinking starts by a sensory branch of the trigeminal nerve  as the afferent arm and a motor branch of the facial nerve as the efferent arm. Blinking may be suppressed when sensory innervation is severed by flap formation, and it may also be modified by other environmental and psychological factors .Corneal sensitivity at the central and paracentral areas  is knownIn confocal microscopy, the corneas of rabbits demonstrated epithelial and basal epithelial/subepithelial nerve disappearances from the flap (excluding its hinge) after LASIK . The denThe therapeutic approach is to stabilize the tear film, increase lubricity, increase aqueous production, and, overall, create a more normal tear environment. Ocular surface management significantly minimized LASIK-induced decreases in goblet cell density and reduced dry eye symptoms . IntensiA new formulation of cyclosporine 0.1% cationic emulsion (IKERVIS) was introduced recently in Europe for the treatment of severe keratitis in adult patients with dry eye disease, which has not improved despite treatment with tear substitutes . StudiesStreptomyces tsukubaensis, is another immunosuppressive agent, but its immunosuppressive potential is higher than that of cyclosporine [Tacrolimus, a macrolide produced by osporine ; tacroliosporine , 86; stuosporine .α-stimulated gene/protein-6, interleukin-1 receptor antagonist, antitumor necrosis factor-α therapy, and anti-interleukin-17 hold a promising future in the treatment of dry eye disease. However, although many biologics have been thoroughly investigated in animal models, human studies remain scarce and well-designed human trials are required to further assess their therapeutic role [Biologic molecules such as lubricin (proteoglycan-4), recombinant human nerve growth factor, tumor necrosis factor tic role .Punctal plugs are a safe, effective, and reversible method of preserving aqueous and artificial tears on the ocular surface in order to reduce the signs and symptoms of dry eye . PunctalTreatment for dry eye has included topical steroids , bandagePlatelet-rich plasma showed evidence for promoting the subbasal nerve plexus regeneration after LASIK. However, it provided no positive effect on the recovery of corneal sensitivity, probably due to the limited bioavailability of growth factors in the corneal stroma when platelet-rich plasma is topically administered . TopicalDry eye continues to be the most frequent complication of LASIK, occurring in nearly all patients and fortunately resolving in the vast majority within the first postoperative year. From our experience, preexisting dry eye is the most significant risk factor for severe and prolong postoperative dry eye; therefore, careful preoperative evaluation for signs and symptoms of dry eye is crucial for identifying patients who are prone to develop severe dry eye postsurgery. A thorough preoperative expectation management is to be done, and patients should be advised that they have a significantly increased risk for developing long standing and even chronic post-LASIK dry eye, which could potentially influence the refractive outcome. Other factors that could influence dryness post-LASIK are controversial: for example, it is possible that patients requiring high refractive corrections are at an increased risk for developing chronic dry eye and regression. Enhancement surgery may exacerbate chronic post-LASIK dry eye and therefore should be considered with caution in patients with chronic dry eyes. The ocular surface and tear film must be well managed before the surgery and for several months afterwards. This should be done with stepwise management first with preservative-free artificial tears and, if needed, with the use of topical cyclosporine A, topical autologous serum tears, and punctal occlusion. Treatment is important not only to alleviate ocular discomfort and dryness but also to improve vision quality and refractive results.


Trichloroacetic acid (TCAA), or trichloroethanoic acid, is a chemical analogue of acetic acid where three methyl group hydrogen atoms are replaced by chlorine. TCAAs are also abbreviated and referred to as TCAs, causing confusion with the psychiatric antidepressant drug class, especially among patients. TCAAs exist in dermatological treatments such as chemical peels or wart chemoablation medication. TCAA ingestion or overdose can cause gastric irritation symptoms including vomiting, diarrhea, or lassitude. This symptomatology is less severe than TCA overdose, where symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest. Owing to the vast difference in symptoms, the need for clinical intervention differs greatly. While overdose of either in a self-harm attempt can warrant psychiatric hospital admission, the risk of death in TCAA ingestion is far less. A patient ingested TCAA in the form of a commercially available dermatological chemical peel as a self-harm attempt, thinking that it was a more injurious TCA. Awareness among physicians, particularly psychiatrists, regarding this relatively obscure chemical compound (TCAA) and its use by suicidal patients mistakenly believing it to be a substance that can be significantly more lethal (TCA), is imperative. Chemexfoliation  is used to obtain both therapeutic and cosmetic benefits . TCAA, fThis report describes a patient who previously developed mild symptoms related to a TCAA overdose in a self-harm attempt while believing it to contain a TCA. The objective is to draw attention that this type of overdose which, while rare, may warrant awareness of the commercial availability of TCAAs for patients and the possibility of their use in self-harm behaviors.A 19-year-old female was evaluated at the Department of Adult Psychiatry Outpatient Clinic with complaints of lack of enjoyment of pleasurable activities, sleep disturbances, suicidal thoughts, and self-induced injury at times of high stress via superficial cutting behaviors on her forearms. These symptoms were in association with ongoing family conflict with her mother and her sister with whom she lived.At the psychiatric evaluation, she expressed that her self-esteem was strongly affected by her turbulent family relationships, and she seemed extremely unhappy. She reported superficial cutting behaviors at least 2 times a week, usually in an impulsive fashion. Laboratory evaluations including hemogram, liver function tests, total protein, vitamin B12, folic acid, T3, T4, and TSH were within normal limits. Baseline psychiatric evaluation with the Beck Depression Inventory (BDI-II) revealed scores of 21 (moderate depression) . AccordiWhile she was under follow-up at the Department of Adult Psychiatry Outpatient Clinic, she admitted to a prior ingestion of a portion of a small bottle (less than 30 milliliters per her description of the product packaging) of a commercially available chemical skin exfoliator containing TCAA. This consumption was impulsive per her description and occurred after an argument with her mother. While such products available over the counter can typically range from 8% to 30% TCAA ingredient which determines strength, she did not recall what percentage of TCAA was in the product . She hadIn clinical psychiatric practice, treating a patient with impulsivity related to poor coping skills and self-harm desire related to borderline personality disorder can be challenging. Less common self-harm attempts via ingestion of a wide array of chemical substances and even objects can occur with these patients. Foreign body ingestion cases have been well documented in the literature , 10. SelThe differentiation between various rare substances, including herbal, homeopathic, and cosmetic products available on the market, can also be extremely difficult for physicians. The resulting consequences from misuse of such substances can pose further problems in the diagnosis and management of patients who ingest these products in self-harm or suicide attempts.In the present case, although response was achieved through psychological and pharmacological treatment with regard to the patient's mental health diagnoses, the report of a prior impulsive self-harm ingestion of a relatively rarely encountered substance was cause for alarm. Exploration as to the patient's motives for this ingestion was warranted and thus uncovered that she misunderstood the nature of the product. She confused a TCAA skin peel with a traditional antidepressant TCA. This discussion led to further clinical characterization of the patient's perceived lethality of the substance. Her previous desire for self-harm was evident regardless of the substance's actual ability to harm. In conclusion, physicians and, especially, psychiatrists should remain mindful of the relatively obscure chemical compounds that may be used in overdose, especially by suicidal patients who believe the substance to be of increased lethality.


Viruses are increasingly recognized as emerging infectious disease agents in both humans and animals. Zoonotic viruses, in particular, often evolve rapidly to adapt to new hosts with enhanced virulence and emerge or re-emerge to cause epidemics. Factors such as urbanization, global warming, and dense human and animal populations may have contributed to the emergence of some viruses. The recent epidemics caused by Zika virus and Middle East respiratory syndrome coronavirus (MERS-CoV) clearly illustrate the ability of emerging viruses to pose huge public health problems within a short time. Much more research effort is needed to understand the evolution and pathogenesis of these emerging viruses, as well as the development of diagnostics and therapeutics to combat existing and future epidemics. Recent advances in molecular techniques, such as sequencing and metagenomics, have accelerated our understanding of genetic and host diversity of emerging viruses, and hence their evolutionary pathways. Nevertheless, many questions remain unanswered. For example, while severe acute respiratory syndrome coronavirus (SARS-CoV) was originated from horseshoe bats as the primary reservoir ,2, the aIn this special issue, “Molecular Research on Emerging Viruses: Evolution, Diagnostics, Pathogenesis, and Therapeutics”, insights into advances and discoveries in understanding the different aspects of various emerging viruses are given by eight original studies and four review articles.Aedes aegypti mosquitoes was found to facilitate viral replication, suggesting the importance of pathogen–pathogen interactions. In another article, Lu et al. investigated the antiviral activity of histone deacetylase (HDAC) inhibitors as host-targeting agents against Japanese encephalitis virus (JEV) [Three articles focus on arthropod-borne viruses (arboviruses) which are important emerging pathogens having caused various epidemics in recent years. In the systematic review and meta-analysis study by Coelho et al., the prevalence of microcephaly in infants born to Zika virus-infected women among all pregnancies was estimated , which mus (JEV) . TubacinZoonotic influenza viruses remain a significant concern to both human health and food industry, with their tendency to re-assort and mutate to generate novel strains capable of interspecies transmission. Yet, it remains difficult to predict the emergence potential of new strains. In the article by Eng et al., a machine learning approach was taken to build a zoonotic strain prediction model which could classify avian, human, or zoonotic strains with an estimated zoonotic risk . In anotHepatitis viruses pose significant disease burdens worldwide and some have emerged or re-emerged in different populations. In the review article by Sridhar et al., the genotypic diversity and evolution of existing hepatitis E virus strains are reviewed, with a special focus on the emergence of camel hepatitis E variants . In anotCoronaviruses have continued to emerge or re-emerge in the last two decades to cause epidemics in humans and animals. In the review article by Lin et al., current knowledge on the molecular evolution, pathogenicity, and epidemiology of infectious bronchitis virus, which poses huge economic threats to poultry farms worldwide, was summarized . Enteroviruses are another group of emerging viruses that can cause severe sporadic infections or epidemics especially in young children. In particular, enterovirus-D68 has emerged in recent years in various countries and is increasingly recognized as an important respiratory pathogen in the young and immunocompromised. In the article by Yip et al., the first fatal case of EV-D68 infection and genetic diversity of EV-D68 strains in Hong Kong were described . The stuISG12A) in restricting PRRSV replication [ISG12A was found to be upregulated in cells or tissues of pigs and could suppress PRRSV replication in infected MARC-145 cells, supporting its role in host immune response to PRRSV. In another article, Liang et al. describes the transcriptomic differences in porcine alveolar macrophages from two different pig breeds, Tongcheng and Large White pigs, in response to PRRSV infections [Two articles report on the virus–host interaction during porcine reproductive and respiratory syndrome virus (PRRSV) infection which causes severe losses in the swine industry worldwide. In one article, Ji et al. describes the role of porcine interferon stimulated gene 12a (lication . ISG12A fections . TranscrLast but not least, some mammalian arenaviruses are emerging viruses that may infect humans to cause lethal hemorrhagic fever. In the article by Ly, current knowledge on the differential immune responses to arenaviruses were summarized, which may help understand their pathogenesis and contribute to the development of vaccines .


The aim of this review is to highlight recent advancements, current trends, and the expanding role for cardiac CT (CCT) in the evaluation of ischemic heart disease, nonischemic cardiomyopathies, and some specific congenital myocardial disease states.CCT is a highly versatile imaging modality for the assessment of numerous cardiovascular disease states. Coronary CT angiography (CCTA) is now a well-established first-line imaging modality for the exclusion of significant coronary artery disease (CAD); however, CCTA has modest positive predictive value and specificity for diagnosing obstructive CAD in addition to limited capability to evaluate myocardial tissue characteristics.CTP, when combined with CCTA, presents the potential for full functional and anatomic assessment with a single modality. CCT is a useful adjunct in select patients to both TTE and CMR in the evaluation of ventricular volumes and systolic function. Newer applications, such as dynamic CTP and DECT, are promising diagnostic tools offering the possibility of more quantitative assessment of ischemia. The superior spatial resolution and volumetric acquisition of CCT has an important role in the diagnosis of other nonischemic causes of cardiomyopathies. Cardiovascular disease remains the worldwide leading cause of morbidity and mortality accounting for up to 31% of all deaths , 3. NumeTransthoracic echocardiography (TTE) is the most widely available and commonly used technique for assessing cardiac structure and function. However, TTE assessment may be suboptimal in certain subsets of patients, namely those with poor imaging windows due to lung disease, obesity, chest wall defects, or overlying dressings in burn and post-surgical patients. CMR imaging is a powerful adjunctive test in these patients and is the current gold standard for assessment of cardiac volumes and systolic function. Compared with TTE and CMR, CCT has superior spatial resolution with decreased but comparable temporal resolution , 10. QuaMyocardial assessment in ischemic heart disease encompasses both the anatomical assessment of the cardiac dimensions and structure as well as indirectly assessing coronary artery stenosis severity and CAD chronicity. There is a complex interaction between observed coronary anatomy  and the presence of ischemia. Published data demonstrates that a luminal stenosis ≥ 50% by CCTA correlates poorly with myocardial ischemia by either single-photon emission computed tomography (SPECT) or positron emission tomography (PET) with positive predictive value (PPV) ranging from 29 to 58% . ConversThe last decade has witnessed a shift in the diagnostic approach for ischemic heart disease away from the utilization of a single functional testing modality followed by ICA to a patient-centered multimodality approach. This approach takes into account patient parameters, preferences, and radiation dose considerations to guide therapy. As such, providers tasked with the evaluation of ischemic heart disease need a baseline understanding of the strengths and limitations of available modalities to allow for a multimodality imaging approach to these patients.SPECT is a static imaging modality that leverages differential distribution and uptake of modest energy 70–120 keV) radiotracers within the myocardium based on differences in coronary blood flow and myocardial viability. SPECT imaging, compared to iFFR, has a sensitivity of 74% and specificity of 79% for the diagnosis of significant obstructive CAD  keV radi, 22. ObePET is a versatile nuclear imaging modality that detects high-energy (512 keV) photons that result from an annihilation interaction between a positron and a valence electron. In addition to static perfusion data, the radiotracers Rb-82 and 13N-ammonia can be used to quantify absolute coronary blood flow and coronary flow reserve , 30. ViaCMR is the gold standard for the assessment of cardiac structure and function. Additionally, with emerging applications such as T1 mapping, CMR is the best validated noninvasive modality for tissue characterization. The addition of intravenous gadolinium allows for both first-pass stress imaging, utilizing gradient echo sequences, for the assessment of myocardial ischemia , 33. ComCCT is an emerging application with the potential to deliver coronary anatomy and functional significance in a single scan. Utilizing vasodilator stress agents, CCT is able to assess differences in myocardial distribution of iodinated contrast, a technique referred to broadly as cardiac CT perfusion (CTP) •. CTP prCTP relies on the kinetic properties of iodinated contrast as it is distributed and taken up into myocardial tissue. CTP imaging involves rest and stress acquisitions and can be performed in a static or dynamic method. Figure Rest first, followed by stress image acquisition protocol, is the most widely used in clinical practice and is best suited for low- to intermediate-risk patients without known CAD Fig. a. This pLess commonly used when compared to rest-stress, stress-first CTP is best suited for patients with intermediate to high pretest risk known intermediate/indeterminate stenosis, or prior revascularization where the assessment of ischemia in a particular vascular territory is favored over coronary anatomy Fig. b. When pz-axis coverage up to 105 mm and, thus, can image the cardiac volume without the need for table shuttling [Static imaging techniques, with or without stress acquisitions, are limited to single snapshots in time and do not provide comprehensive blood flow analysis. Historically, limitations in scanner technology made static CTP the only viable method. However, the latest generation 256- and 320-row detector platforms allow for imaging of the entire cardiac volume with a stationary table and a single gantry rotation. Additionally, second-generation dual-source CT (DSCT) can cover this same volume utilizing a table shuttle method. The third-generation DSCT has increased huttling , 55, 71.huttling . MBF calhuttling , 73. In huttling , 60. Thehuttling , 73. DynDECT was first introduced in 2008 and has undergone several advancements and innovations in the last decade that have significantly increased its diagnostic utility , 75. DECPost-processing of CTP datasets relies on the visual assessment of the ischemic myocardial segments in comparison to normally perfused myocardium Fig. . MultiplRadiation dose, as mentioned above, continues to be a limitation to widespread implementation of CTP protocols. Newer generation scanners and the possibility of single acquisition CCTA and stress CTP hold promise for lowering radiation dose to levels more comparable to SPECT. Imaging artifacts, specifically beam hardening from the descending thoracic aorta, can affect interpretation of the inferolateral wall segments by mimicking a perfusion defect in that territory. Utilization of beta-blockers and nitrates, as is often required for acquisition of CCTA data, reduces the sensitivity of CTP scans by masking smaller, typically single-vessel, perfusion defects as shown in the SPECT literature , 99. FinOver the last two decades, advancement in CMR with LGE has revolutionized the assessment of myocardial fibrosis secondary to infarction, infiltration, or inflammation. The ability of CMR to assess these various tissue states is based on the pathologic effects on the tissues resulting in changes in tissue density and differential uptake of gadolinium. Iodinated contrast has similar kinetics and distribution to gadolinium allowing for the potential of DECT to detect infarction similar to CMR . As mentCCT can serve as an important adjunctive modality to TTE in patients with known or suspected cardiomyopathies, primarily in patients with claustrophobia, implantable cardiac devices, and poor TTE windows. In the setting of newly diagnosed heart failure with a reduced ejection fraction, CCTA is well validated to exclude significant CAD in patients with low to intermediate pretest risk of CAD. In patients with reduced EF less than 35%, CCTA for the evaluation of CAD has a reported sensitivity of 98% and specificity of 97% . While a18F-fluorodeoxyglucose (FDG). FDG PET imaging, taking advantage of differences in glucose metabolism between normal myocytes and diseased myocytes, has the ability to detect hibernating myocardium in viability testing and myocyte inflammation as seen in acute cardiac sarcoidosis [PET when combined with CT has emerged as a powerful diagnostic modality, both in ischemic heart disease as well as various inflammatory and infiltrative disease processes. PET imaging is commonly undertaken to assess the metabolic activity of tissue utilizing the glucose analog coidosis . Imagingcoidosis .While the utility of DE images has been discussed as it relates to infarct detection in ischemic heart disease, iodine mapping with single- or dual-energy CT can also be employed in the assessment of other cardiomyopathies where epicardial and midmyocardial scar patterns are currently observed on CMR exclusively. CCT-based estimation of extracellular volume (ECV) by CCT may become a useful diagnostic and prognostic marker of myocardial remodeling similar to that observed with T1 mapping by CMR –113. StrCCT in the form of CTP, particularly when combined with CCTA, is a powerful tool in the assessment of ischemic heart disease and, with newer generation scanner platforms, presents the potential for full functional and anatomic assessment with a single contrast injection and low radiation dose dataset acquisition. CCT is a useful adjunct to both TTE and CMR in the evaluation of ventricular volumes and systolic function, particularly in patients with implantable cardiac devices or severe claustrophobia. Newer applications of CCT, namely dynamic CTP and DECT, are promising diagnostic tools offering the possibility of more quantitative assessment of ischemia than offered by static perfusion imaging. Finally, given its superior spatial resolution and volumetric acquisition, CCT has an important role in the diagnosis of other nonischemic causes of cardiomyopathies most notably LVNC, ARVC, and HCM.


Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery.Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates.Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% . Geriatric syndromes were important predictors of delirium, namely history of delirium , frailty , cognitive impairment , impairment in activities of daily living , and impairment in instrumental activities of daily living . Potentially modifiable prognostic factors such as psychotropic medication use  and smoking status (OR 1.8 95% CI 1.3–2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium .Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care.The online version of this article (10.1007/s11606-017-4204-x) contains supplementary material, which is available to authorized users. The purpose of our systematic review is to identify preoperative patient characteristics of older adults undergoing elective surgery that either predispose them to or protect them from developing postoperative delirium. We also present the pooled prevalence of postoperative delirium and the risk of delirium-related adverse outcomes from these studies. This information can be used by clinicians and patients to enhance medical decision-making and by researchers to study possible interventions aimed at lowering the incidence of postoperative delirium among older adults undergoing elective surgery.,This study was reported in accordance with both the PRISMA statement for reporting systematic reviews and meta-analyses and the MOOSE statement for reporting meta-analysis of observational studies in epidemiology.,Prospective studies  were eligible if they included older adults undergoing elective surgery  and reported prognostic factors associated with postoperative delirium or delirium-related adverse outcomes. We limited our search to prospective studies because delirium is not well-captured in patient charts or electronic databases.An experienced librarian searched MEDLINE , EMBASE , CINAHL , Cochrane Central Register of Controlled Trials , and AgeLine  for potentially relevant studies. The full search strategy for MEDLINE : (1) screening of titles and abstracts and (2) full-text screening of articles. Initially, each reviewer independently screened 10% of a random sample of citations to ensure adequate inter-rater agreement. Study authors were contacted for further information if it was unclear whether the study met inclusion criteria. Disagreements concerning article inclusion were resolved through discussion; otherwise, a third reviewer was available to make a final decision.Two levels of screening were completed independently by two reviewers using Two reviewers abstracted data independently from studies retained from level 2 screening. Study characteristics  and prognostic factors associated with postoperative delirium were abstracted from included studies. Definitions operationalized by study authors for individual prognostic factors were also abstracted, where appropriate  for cohort studies.We calculated odds ratios (ORs), mean differences (MDs), or standardized mean differences (SMDs) to quantify the relative risk of prognostic factors associated with postoperative delirium and delirium-related complications. Whenever only continuous effect measures, such as MDs  were reported by study authors, these effect measures were transformed to OR estimates, if needed, to derive an overall effect estimate that combined both dichotomous and continuous study-level effect estimates.2 statistic and thresholds for its interpretation were consistent with those reported in the Cochrane Handbook for Systematic Reviews of Interventions.p-value <0.05.Random effects models were used to pool incidences of delirium and derive overall effect estimates with 95% CIs when two or more studies reported extractable effect estimates. The NNF was calculated as 1/pooled incidence of delirium. Information regarding data imputation methods to approximate mean and standard deviation values is found in eMethods ,p < 0.05), the trim-and-fill method was used to estimate the number of missing studies and to derive the combined effect estimates, adjusting for publication bias.metafor and meta packages.,Prognostic factors that were reported in at least 10 studies were assessed for publication bias by visual inspection of funnel plots for asymmetry and with the Egger’s test.–,–,–,––,Of the 5692 titles and abstracts that were screened for inclusion, we identified 41 studies (9384 patients) that reported prognostic factors associated with the risk of developing postoperative delirium and its consequences . The pooled incidence of delirium varied by surgical type: cardiac , orthopedic , general , vascular , and urological surgery .The pooled incidence of postoperative delirium among included studies was 18.7% ; however, among a subgroup of current smokers, there was an association between smoking and postoperative delirium .In a subgroup analysis of patients who reported a history of alcohol abuse, there was no significant effect on the development of postoperative delirium ; however, the two studies included in this summary effect measure were clinically heterogeneous. The study by Bakker et al. reported renal insufficiency as a measure of serum creatinine level and found no significant association between renal insufficiency and postoperative delirium, whereas the study by Sasajima et al., reported the number of patients with end-stage renal disease, which was significantly associated with postoperative delirium.,2 = 96.1%) and cognitive impairment . Additionally, when only those studies reporting the age-adjusted odds of postoperative delirium among older adults with cognitive impairment were included in the sensitivity analysis, there was still a significant association . Among the prognostic factors that were not significantly associated with postoperative delirium in the original meta-analyses, only the association between hypertension and postoperative delirium was statistically significant . There were a number of studies that reported only unadjusted ORs, which precluded sensitivity analysis . It was estimated that five studies with non-significant results may have been suppressed, although even after adjusting for these potentially missing studies, cognitive impairment remained a significant risk factor . We also identified prognostic factors associated with the risk of postoperative delirium in this patient population. Common geriatric syndromes, including cognitive and functional impairment, were shown to be important prognostic factors that are identifiable during the preoperative assessment of older adults. Findings from our systematic review support the targeting of potentially modifiable  and protective (caregiver support) factors to optimize care. Furthermore, we showed that delirium is associated with adverse outcomes that can severely impact both the quality and quantity of life experienced by older adults following elective surgery.,In addition to non-pharmacological delirium prevention strategies that have demonstrated effectiveness in both the medical and surgical settings, other potential targets for intervention were identified in this study that warrant further research.,,Although some would argue that there are no effective interventions for the treatment of frailty, researchers have shown that the progression of frailty is potentially preventable.Importantly, the availability of a caregiver in the perioperative period was shown to be protective against developing postoperative delirium. This is consistent with a randomized trial in older adults with hip fractures, which showed that a non-pharmacological multicomponent intervention provided by caregivers in the perioperative setting was associated with a decreased incidence of delirium.,,In contrast to recent systematic reviews and meta-analyses on adverse postoperative outcomes among older adults, which have included patients with various indications for surgery such as hip fracture or other emergency procedures, we targeted older adults undergoing elective surgery because of the potential to intervene in the preoperative setting to improve patient outcomes.There were limitations in our study’s review process. First, only studies that were published in English were included in this review to increase feasibility, but our findings are likely generalizable given the number of geographical regions represented in our systematic review. Second, there was substantial heterogeneity among studies for some outcomes, which could not always be adequately explored given a limited number of studies and a lack of individual patient-level data. There were also limitations in the studies themselves. The methodological quality assessment demonstrated that a number of studies reported varying lengths and intensity of follow-up, which may have impacted the incidence of delirium reported. Although some studies reported only unadjusted effect measures, which limited their ability to account for possible confounders, our sensitivity analyses demonstrated that our findings were largely consistent when only study-level effect estimates adjusted for important confounders were included in the meta-analyses.Our study had a number of strengths. Forty-one studies and over 9000 patients were included in our systematic review and meta-analysis, which allowed us to investigate a number of possible protective and predisposing factors. The hypothesis-generating nature of this study allowed for the identification of important prognostic factors, including the availability of caregiver support, which has potentially important clinical and policy implications for patient care.In summary, postoperative delirium is a common (NNF = 6), yet preventable, complication experienced by older adults undergoing elective surgery that can lead to prolonged hospitalization, the inability to return home, and death. This systematic review and meta-analysis identified protective and modifiable prognostic factors, including smoking, frailty, and psychotropic medication use, which should be further studied to develop interventions aimed at mitigating potential harm.ESM 1(DOCX 1580 kb)ESM 2(DOCX 28 kb)


An “exosome” is a nanoscale membrane vesicle derived from cell endocytosis that functions as an important intercellular communication mediator regulating the exchange of proteins and genetic materials between donor and surrounding cells. Exosomes secreted by normal and cancer cells participate in tumor initiation, progression, invasion, and metastasis. Furthermore, immune cells and cancer cells exert a two-way bidirectional regulatory effect on tumor immunity by exchanging exosomes. Current studies on exosomes have further expanded their known functions in physiological and pathological processes. The purpose of this review is to describe their discovery and biological functions in the context of their enormous potential in the clinical diagnosis, prevention, and treatment of cancer as well as bacterial and viral infectious diseases. The concept of “exosomes” was originally referring to membrane vesicles obtained from biological fluids following studies that reported the secretion of 50 nm-sized vesicles from reticulocytes, which were associated with the transferrin receptor during the maturation process . Later, Various types of mammalian cells release EVs into surrounding tissues or cells for intracellular communication. Being generally recognized as having a secretory vesicle structure, EVs are currently divided into two main categories: exosomes derived from the endocytic pathway or microvesicles derived from cell membrane shedding, which includes ectosomes and microparticles . In addiExtracellular vesicles are small spherical bio-membrane structures, which include microparticles and exosomes , secreteIn recent years, exosomes have received significant attention from researchers because they transport functional molecules, such as messenger RNA (mRNA), microRNA (miRNA), and protein, into target tissues or cells. These bioactive molecules are considerably stable and can modulate cell behaviors in recipient cells. There is increasing evidence supporting the hypothesis that exosomes secreted by various cells play roles in many physiological and pathological processes, especially in cancer. In this review, we briefly summarize the most recent data and findings concerning the function of exosomes and discuss their potential role in diagnosis and therapeutic regimens of human diseases.Figure 1). The main difficulty faced in exosome research is improvement of available EV extraction and analysis methods. Currently, differential velocity centrifugation methods are used to extract exosomes from the supernatants of fetal bovine serum cultured cells in the absence of cattle-derived EVs. Exosomes and other EVs are spherical and have a lower buoyant density than that of other non-membrane fragments  Exosomes are used as a signal complex directly stimulating recipient cells through binding to a cell surface ligand; (2) Exosomes transfer receptors between cells; (3) Exosomes deliver functional proteins or infectious particles to recipient cells; and (4) Exosomes transfer genetic information to recipient cells through mRNAs, microRNAs, or transcription factors . Once exFigure 2). Virus-infected cells secrete protein, lipids and RNA through exosomes, thereby enabling it to cause further infection in the host  by macrophages. The exosomes released by Leishmania can also modulate immunity by promoting secretion of the immunosuppressive factor interleukin-10 (IL-10) or by conditionally inhibiting secretion of tumor necrosis factor (TNF) caused by interferon-γ (IFN-γ)  . Therefo effects . CollectFigure 3). Recent studies have elaborated on the prominent role of exosomes in tumor carcinogenesis. EGFR, GRB2, and SRC, were enriched in exosomes derived from non-small cell lung cancer cells, which could actively promote the proliferation of recipient cells. Similarly, it was found that EGFRvIII and miR-21 levels in exosomes of patients with glioblastoma were upregulated, and that glioblastoma cells containing RNA- and angiogenesis-relevant proteins could induce tumor growth . Moreover, communication between immune cells and cancer cells via exosomes have dual effects in modulating tumor-related immunity because exosomes can mediate both immune activation and suppression, thereby affecting tumor development.Extracellular vesicles were first discovered as a mechanism for reticulocytes to transfer transferrin during maturation. Because they contain major histocompatibility complexes (MHCs) and present antigens, EVs rapidly attracted the attention of immunologists. An increasing number of studies reported the significant roles of EVs in regulating tumor immunity  and inhibited differentiation of bone marrow precursor cells into DCs  cells are typical cytotoxic lymphocytes that are part of the innate immune system of the body, which mainly act as killer cells . Exosome+ and CD8+ T cells are vital in the anti-tumor immune process. However, tumor-derived exosomes can affect the proliferation, activation, and apoptosis of these types of T cells. Exosomes derived from human nasopharyngeal carcinoma cells carry miRNAs that inhibit proliferation and differentiation of T cells into Th1 and Th17 cells, and promote the formation of regulatory T cells  with high sample throughput. For multiplexed detection, mass spectrometry is used for proteomic analysis of cancer-derived EVs. Because of the extreme complexity and considerable concentration ranges of biomolecules found in plasma samples, current analysis techniques face a great challenge. Numerous conventional methods, such as mass spectrometry, microarrays, and real-time PCR, have significant technical limitations in separation peak capacity, sensitivity, and dynamic range .Extracellular vesicles, including exosomes and other microvesicles, are the basic biological membrane-enveloped structure of organisms released by both normal cells and pathogens. They mediate communication between cells and participate in many physiological and pathological processes. The clinical potential of exosomes has been gradually realized as the breadth and scope of the different functions of exosomes have been determined. Exosomes transport several types of cellular materials, including DNA, mRNA, miRNAs, and proteins, and internalize many receptors, a process that promotes the activation of certain signaling pathways. Furthermore, exosomes can modulate cellular biological processes by changing the expression of biological (possibly therapeutic) targets on the surface of cells as well as regulate the expression of intracellular components. By synthesizing and releasing exosomes, tumor cells promote angiogenesis, which provides a microenvironment that favors proliferation and directional metastasis of tumor cells. Therefore, by targeting the bioactive molecules and surface antigens of exosomes, we can determine tumor progression at the initial stage and prevent metastasis in advance. In addition, tumor-derived exosomes mediate communication between tumor and immune cells, and induce immune activation or suppression in cells of the immune system. Thus, because exosomes regulate tumor immunity in a bidirectional manner the outcome of which is determined as a balance between opposing “yin and yang” effects, exosomes have a key role in anti-tumor immunity, which is of untapped clinical potential. Furthermore, exosomes obtained from viruses and parasites can promote pathogen infection, an understanding of which will enable the development of exosome-mediated strategies to counter infection of pathogenic microorganisms that affect millions of people worldwide.Since the first meeting of the International Society for Extracellular Vesicles (ISEV) in 2013, researchers have invented many terms and names for secreted vesicles based on their different physiological functions including calcifying matrix vesicles that are involved in bone formation, tolerosomes that cause immune tolerance, and prostasomes, which are derived from prostate epithelium. However, “exosomes” and “microvesicles” have been widely applied and are more generic terms. To unify vesicle nomenclature, ISEV recommends using the term “extracellular vesicles” as a generic term for all secreted vesicles . EVs incExosomes are a hot topic for targeted drug research. The design of non-drug small molecule pharmaceuticals that target the secretory pathways of exosomes and other microvesicles have enormous potential and significant prospects. In addition to using exosomes as a novel drug delivery vehicle, considerable efforts have been performed to develop exosome-derived drugs by modifying the contents or surface proteins of tumor-derived exosomes. However, both target specificity and clinical effectiveness require further improvements. Exosomes were originally considered unremarkable vesicle structures, but with our current understanding they have become a global research interest. Exosomes exhibit significant research prospects and exosomes and exosome-derived drugs have the potential to provide more effective methods in the treatment of clinical diseases as well as pathogenic infections. Furthermore, we strongly believe that exosomes will be a critical tool in the prognosis, diagnosis, and treatment of various diseases such as cancer and neurodegenerative disorders as well as bacterial, viral, and parasitic infections.XS, PC, XC, YY, and JX contributed to the discussion and revisions to the manuscript. JW wrote the manuscript and JZ prepared the figures.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.


In this Perspective, Lynne Mofenson discusses the implications of Mugwanya and colleagues' findings for protection of women against HIV infection during breastfeeding. Pre-exposure prophylaxis (PrEP) using either daily oral tenofovir disoproxil fumarate (TDF) or co-formulated TDF/emtricitabine (TDF/FTC) has been shown in clinical trials to be effective for prevention of HIV acquisition in men who have sex with men, heterosexual men and women, and persons who inject drugs . HoweverIn 2015, the World Health Organization (WHO) recommended PrEP as “an additional prevention choice for people at substantial risk of HIV infection, as part of combination HIV prevention approaches,” defining “substantial risk” as HIV incidence >3 per 100 person-years in the absence of PrEP ” . Thus, tPLOS Medicine significantly contributes to the accumulating safety data for PrEP in breastfeeding women [The accompanying Research Article by Kenneth Mugwanya and colleagues in ng women . This dong women –8. In inng women .The data provided by Mugwanya and colleagues’ study and others are important because sustained high HIV incidence among adolescent and young women in sub-Saharan Africa constitutes a significant public health emergency ,13. HIV Although limited, most data on TDF during pregnancy are from HIV-infected women receiving combination antiretroviral therapy (ART), with the majority of studies in HIV-infected women on ART and their infants showing no adverse effects of TDF exposure –20. HoweTDF has been used for prevention of perinatal hepatitis B virus (HBV) transmission in HBV-infected pregnant women with high concentrations of HBV DNA, for whom the risk of perinatal HBV transmission is high even when the infant receives hepatitis B immunoglobulin and HBV vaccine . In thesTDF and TDF/FTC have been evaluated in oral PrEP randomized, controlled clinical trials that included non-pregnant women of child-bearing age, in which pregnancies have occurred in women receiving PrEP at the time of conception. Two of these trials have reported on pregnancy outcomes in such women, reporting no difference in adverse pregnancy outcomes between active and placebo arms ,26. HoweGiven that young women, particularly if pregnant or breastfeeding, in sub-Saharan Africa experience some of the highest incidence rates of HIV infection globally, the benefits of HIV prevention in pregnant and breastfeeding women and their infants in these regions, given the currently available evidence, seem to clearly outweigh the risks observed to date. A recent decision analytic modelling study found that the HIV prevention benefit of providing PrEP to pregnant and breastfeeding women in sub-Saharan Africa outweighed even a substantially increased risk of preterm birth (as high as 30%) . For HIVAlthough WHO calls for further research, current WHO guidelines are permissive for use of PrEP during pregnancy and breastfeeding, noting growing evidence for safety from maternal HIV and HBV studies ; WHO is


Detailed metabolic profiling in large-scale epidemiologic studies has uncovered novel biomarkers for cardiometabolic diseases and clarified the molecular associations of established risk factors. A quantitative metabolomics platform based on nuclear magnetic resonance spectroscopy has found widespread use, already profiling over 400,000 blood samples. Over 200 metabolic measures are quantified per sample; in addition to many biomarkers routinely used in epidemiology, the method simultaneously provides fine-grained lipoprotein subclass profiling and quantification of circulating fatty acids, amino acids, gluconeogenesis-related metabolites, and many other molecules from multiple metabolic pathways. Here we focus on applications of magnetic resonance metabolomics for quantifying circulating biomarkers in large-scale epidemiology. We highlight the molecular characterization of risk factors, use of Mendelian randomization, and the key issues of study design and analyses of metabolic profiling for epidemiology. We also detail how integration of metabolic profiling data with genetics can enhance drug development. We discuss why quantitative metabolic profiling is becoming widespread in epidemiology and biobanking. Although large-scale applications of metabolic profiling are still novel, it seems likely that comprehensive biomarker data will contribute to etiologic understanding of various diseases and abilities to predict disease risks, with the potential to translate into multiple clinical settings. Omics profiling—genomics, epigenetics, proteomics, and metabolomics—is becoming increasingly widespread in the worldwide efforts to prevent noncommunicable diseases. This is driven by the quest for better etiologic understanding but also importantly by technical developments that allow quantitative high-throughput methodologies for several -omics, notably genome-wide single nucleotide polymorphisms , 2, genoGeneral aspects of design and analysis of metabolomics studies in epidemiologic research has recently been reviewed in this journal . In thisNMR-based lipoprotein quantification has a long history , 25, 26.In addition to analyses of lipoprotein measures, recently extensively reviewed by Mallol et al. , NMR spehttps://academic.oup.com/aje). A multitude of metabolic measures is quantified directly from serum in a single experiment. The profiling covers both standard lipid measures and a wealth of other metabolic biomarkers. In contrast to other NMR methodologies of advanced lipoprotein profiling , singleP ≈ 0.001. However, we always advocate replication to judge the robustness of metabolic associations rather than relying on cutpoints for statistical significance.Quantitative metabolomics data allow for hypothesis-driven and hypothesis-free research approaches both. In the case of biomarkers not previously investigated in large cohorts, the hypothesis-free approach feeds hypothesis generation—if there are no prior data on a particular biomarker, an informed hypothesis is unlikely. Regardless of the analytic approach, demonstrating replication in independent samples is important. By replication we do not mean that separate discovery and replication cohorts  would bBy mid-2016, over 400,000 blood samples from some 150 epidemiologic and clinical studies had been profiled using this NMR platform. These include the INTERVAL study, a randomized trial of blood donors with more than 46,000 individuals ; the LonMany risk factors plausibly affect multiple molecular pathways, but the extent of this is largely unknown because of the inability to study comprehensive influences on systemic metabolism until recently. Determining the metabolic association patterns across multiple pathways can also help to pinpoint similarities in the molecular signatures of different risk factors, as in the case of body mass index (BMI) and birth weight , 73.Our study on metabolic signatures of adiposity in 12,644 adolescents and young adults illustrates the metabolically diverse effects of BMI . BMI wasThe overall patterns of metabolic associations were similar for cross-sectional and causal estimates. To summarize the causal influences of adiposity across the comprehensive metabolic profile, we charted all causal effect estimates against the corresponding cross-sectional associations . The cloMetabolic profiling of clinical trial samples can be an important resource to assess risk prediction in specific patient groups as well as to provide improved understanding of the molecular effects of interventions. By exploiting various epidemiologic study designs, it may be possible to estimate the metabolic effects of certain drugs even when randomized evidence is not available. For instance, this can be done by examining the metabolic changes associated with starting and stopping the pharmacological treatment in longitudinal studies of observational cohorts, as we have recently demonstrated with statins  and hormStatins reduce LDL cholesterol concentration by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR), leading to a proportionate reduction in CVD risk. Statins have been ascribed myriads of pleiotropic properties beyond lowering LDL cholesterol, yet the effects on many lipids and other biomarkers have not been assessed in large studies, primarily due to lack of affordable means. Because no randomized trial data on the metabolic biomarkers were available in our proof-of-concept study , the detHMGCR gene as an unconfounded proxy for the pharmacological action of statins. Specifically, we examined the metabolic effects of genetically induced HMGCR inhibition—mimicking a very small statin dose—and compared the metabolic association pattern with HMGCR genotypes to the metabolic changes observed longitudinally. We found striking concordance between the observational effects of statins on the metabolic profile and the corresponding associations with the genetic variant in HMGCR.To verify that the observed metabolic changes were actually due to the effects of statins, the analyses were corroborated via Mendelian randomization by using a genetic variant in the The combination of metabolomics data with genetic data in a large number of individuals readily extends beyond studying statin effects. This type of Mendelian-randomization study design can be seen as a “natural” clinical trial . Due to The studies summarized in Table Web MaterialClick here for additional data file.


The purpose of this study was to provide a review of the publications of the risk perceptions or anxiety regarding radiation among people living in Japan after the 2011 Fukushima nuclear power plant accident. Two database (MEDLINE and PsycINFO) and hand-searched the references in identified publications were searched. For each identified publication, the measurements and time related-change of risk perception and anxiety regarding radiation were summarized. Twenty-four publications were identified. Quantitative measures of risk perception or anxiety were roughly divided into two types: single-item Likert scales that measure anxiety about radiation; and theoretical, or model-based measures. Rates of Fukushima residents with radiation-related anxiety decreased from 2012 to 2015. Factors governing risk perception or radiation-related anxiety were summarized by demographics, disaster-related stressors, trusted information, and radiation-related variables. The effects of risk perception or anxiety regarding radiation were summarized as severe distress, intention to leave employment or not to return home, or other dimensions. This review provides summary of current findings on risk perception or anxiety regarding radiation in Japan after the accident. Further researches are needed about detailed statistical analysis for time-related change and causality among variables. The Fukushima Daiichi nuclear power plant  accident following the Great East Japan Earthquake of 11 March 2011 released radionuclides that caused both internal and external exposure [It has been determined that the FDNPP accident caused public anxiety about a variety of hazards, especially nuclear power and nuclear accidents ,4,5. In Anxiety about radionuclides can be explained by the characteristics of human perception of risk. Slovic  divided In general, risk perceptions are important factors affecting psychological distress , as wellmeasures used to assess risk perception and anxiety;the change of risk perception and anxiety with time and their modifiability by intervention;factors governing risk perception and anxiety; and,effects of risk perception and anxiety on residents.Here we present a systematic review of studies of radiation perception and anxiety to allow a better understanding of radiation exposure, psychological distress, and physical health effects after the disaster ,13,14,15We searched the MEDLINE, PsycINFO online databases for publications published between March 2011 and 16 May 2017 and later hand-searched the references in those selected . We alsoParticipants of the survey or intervention were living in Japan.Surveys included measurement of risk perception factors or of anxiety regarding radiation after the 2011 FDNPP accident.Factors governing risk perception and anxiety were investigated.The effects of risk perception and anxiety were investigated.Search keywords included “perception or anxiety or anxieties”, “radiation or radionuclide or radionuclides or radioactive”, and “Fukushima”, in different combinations. Two independent raters (YT and MM) screened the titles and abstracts of each article by the following criteria:Included articles satisfied both criteria A and B, and either C or D. The consistency of raters’ evaluations was examined with Cohen’s kappa coefficient. Discrepancies between ratings were resolved via discussion between the raters. When considering that international readers’ accessibility and interpretation of original papers, we excluded articles written in languages other than English, chapters in books, and letters that did not include measurements of factors influencing radiation risk perception.p < 0.001). Evaluation of the full text against the eligibility criteria left 19 articles [Initially, 117 studies were identified . After the duplicates were removed, 105 articles were screened. On the basis of the screening criteria and consensus discussion, 31 papers were retained. Inter-rater consistency was acceptable  factors governing risk perception or anxiety; (b) effects of risk perception or anxiety regarding radiation; (c) and, modifiability of risk perception and anxiety by intervention. These categories were based on the design or hypothesis of each article’s authors, and may not reflect actual causality.The distribution of categories in the included papers is shown in After final screening, we created four categories of subjects. General subjects included residents of Osaka, Tokyo, and Fukushima prefecture (both evacuated and not evacuated) and mothers living in Fukushima city, Miyagi prefecture, and Chiba prefecture (Tokatsu village). Employment-specific subjects included public health nurses, mental health nurses, general nurses, radiation decontamination workers, alpine workers, and rescue workers. Residents of evacuated areas came from Minamisoma city, and Kawachi village (both subject to evacuation orders). We also considered subjects who attended any explanatory meeting or risk communication workshop.The study samples partly overlapped between Suzuki et al.  and Oe esingle-item Likert scales that measure anxiety about radiation; and,theoretical or model-based measures.Distribution of measurement type using in included papers is shown in Single-item Likert scales were the most frequently used measure (54%). They assessed overall or specific radiation-related anxiety. Overall, rating scales asked participants about their degree of radiation-related anxiety using a 1 (no anxiety) to 10 (having a lot of anxiety) or 1 (none) to 4 (very much) Likert scale. One study assessed respondents’ anxiety about radiation exposure using a binary response option (having anxiety: yes or no). Murakami et al.  asked abSpecific anxiety related to the effects of radiation on the development of thyroid cancer ,29 or onTwo theoretical models of risk perception were used: three studies used Slovic’s model  and fourYoshii et al.  asked woAlthough no surveys or studies statistically tested changes in risk perception or anxiety over time, two articles reported descriptive data. Ito et al.  reportedFour indicators in FHMS and POSFP from 2012 to 2015 ,36 refleTwo descriptive and three statistical reports concerned modifiability of risk perception or anxiety by intervention. Fujii et al.  counseleImamura et al.  used a rWe summarized the factors governing risk perception or radiation-related anxiety by demographics ,19,20,32Risk perception and anxiety were consistently high among women ,19,20,32Two studies examined the relationship between trusted information and risk perception or anxiety ,20. MuraAmong participants at explanatory meetings about radiation and the thyroid, anxiety about radiation was related to safety behaviors . Suzuki et al.  and Oe eConsistent with findings from general Fukushima residents, Nukui et al.  revealedMurakami et al.  reportedRadiation-related anxiety was related to intention to leave employment or not to return home ,12. A poChanges in anxiety about radiation were related to perception of dread risk . Risk peThe effects and factors governing risk perception or anxiety are summarized in Single-item measures were frequently used to assess radiation-related anxiety. A simple measure is useful for assessing general or overall anxiety, and can also assess anxieties specific to subject characteristics. Theoretical or model-based measures were less frequently used. These allow generalizability or comparability because fixed items are used across various research contexts. It may be useful to include both measures to allow for both specificity and generalizability. For example, Murakami et al.  used botThere is a need to consider new scales or categories developed since the accident. If we rely only on traditional measures of risk perception, we may overlook important dimensions that are specific to the FDNPP accident and might apply to future nuclear accidents. Newly developed scales cover fear of social disruption and concerns about the effects of information from news reportage on the accident. Thus, it may be useful to assess perceptions about radiation itself, and about how to spread information related to radiation or social consequences, which is one of the most important features of effective risk communication following a nuclear accident.Overall risk perception or anxiety tended to reduce over time. In particular, Lindel’s model of risk perception (genetic effects and delayed effects) showed a remarkable reduction from 2013 to 2014 in residents of Fukushima prefecture. Even following a nuclear accident, the human capacity for resilience might quickly reduce anxiety. One possible reason for this reduction is the implementation of various risk-countermeasure activities, including risk communication. However, the data may be biased because of participants’ characteristics  could not be consistent over time. Thus, changes in risk perception and anxiety with time and related factors should be examined statistically with properly adjusted covariates.The findings of studies of explanatory meetings or one-to-one consultations with medical professionals indicate that such interventions may be useful in reducing radiation-related anxiety. This conclusion is consistent with risk communication situations that empirically shifted to face-to-face communications. The findings suggest that radiation-related anxiety can be modified through interventions. The studies also found that interventions may be useful for people with high radiation-related anxiety, and that communication is more effective among groups that have fewer than 100 participants. On the other hand, interventions that target factors other than radiation-related anxiety may not be useful, although it is possible that the effect of interventions targeted at mental health was overlooked owing to insufficient statistical power in Imamura et al. , which hFollowing a nuclear accident, it may be unethical to conduct a randomized controlled trial to examine the effects of different interventions on anxiety. However, more sophisticated statistical analysis is needed to clarify the effect of interventions on the reduction of radiation-related anxiety or on the eventual outcome so as to help scientists or policymakers to better prepare for future accidents. The use of a counterfactual model of causal inference  could be used to examine causality.The effects and factors governing risk perception or anxiety are summarized in Most factors governing risk perception, including sex, age, habitation, and presence of children generally agreed with findings in elements of environmental and social risk perception or communication ,39,40. IAlthough the importance of public communications that can the recognize perceived risks following disasters has been pointed out , the impFurthermore, risk communication that ignores risk perception factors enhances mistrust among residents. High risk perception regarding radiation itself is natural; however, excessive reactions in avoiding radiation  can cause risk tradeoff problems such as increased lifestyle diseases .One way to resolve nuclear legacy problems is to develop a systematic methodology for socio-psychological support among affected groups living in territories affected by accidents or disasters that responds to cultural environment. Such an attitude will emphasize the importance of populations’ views, opinions, feelings, anxieties, and desires; in this way, risk perception factors related to contaminated environments will help governments and policymakers move toward more effective policymaking and management. For the ultimate success of risk communication, it is crucial to examine and compare the effects of risk perception among demographic groups and tailor risk messages to the concerns, fears, and anxieties of different groups among affected communities. Such an approach will help us improve nuclear safety by design, instead of in response to accidents .This review refers to surveys done in Japan after the accident, and takes into account the location and the distance from the place of the accident. This study provides elements for grounded observations when different studies are matched. Also, the selection of articles and the four categories of findings were well defined. We identified methods for measuring risk perception or anxiety regarding radiation, together with the evolution in time of such anxiety and its effects. In conclusion, this review identified important new factors, and changes observed as a result of intervention. The elements collected by this review can be used to plan further studies and may be useful in developing a sound way to communicate risks.However, this review also has some weaknesses. Most studies that were reviewed were cross-sectional surveys. The authors nominated the relational direction between variables , so any This review provides summary of current findings on risk perception or anxiety regarding radiation in Japan after the accident. Two types of methods were identified to measure risk perception or anxiety about radiation: single-item Likert scales and theoretical or model-based measures. Radiation-related anxiety decreased from 2012 to 2015 among Fukushima residents. Factors governing risk perception or radiation-related anxiety were summarized: demographics, disaster-related stressors, trusted information, and radiation-related variables. The effects of risk perception or anxiety regarding radiation included severe distress, intention to leave employment or not to return home, or other dimensions. Further researches are needed about detailed statistical analysis for time-related change and causality among variables.


Feeding is an essential behavior for animals to sustain their lives. Over the past several decades, many neuropeptides that regulate feeding behavior have been identified in vertebrates. These neuropeptides are called “feeding regulatory neuropeptides.” There have been numerous studies on the role of feeding regulatory neuropeptides in vertebrates including birds. Some feeding regulatory neuropeptides show different effects on feeding behavior between birds and other vertebrates, particularly mammals. The difference is marked with orexigenic neuropeptides. For example, melanin-concentrating hormone, orexin, and motilin, which are regarded as orexigenic neuropeptides in mammals, have no effect on feeding behavior in birds. Furthermore, ghrelin and growth hormone-releasing hormone, which are also known as orexigenic neuropeptides in mammals, suppress feeding behavior in birds. Thus, it is likely that the feeding regulatory mechanism has changed during the evolution of vertebrates. This review summarizes the recent knowledge of peptidergic feeding regulatory factors in birds and discusses the difference in their action between birds and other vertebrates. Gallus gallus domesticus) are raised worldwide for the production of meat and eggs as food for humans. Chickens have been genetically selected for efficient meat and egg production and thereby many strains have been developed. However, they are divided broadly into two strains: One is selected for meat production (meat-type chickens) and the other is for egg production (layer-type chickens)  release from the anterior pituitary, but later work revealed that this peptide is related to regulating feeding in mammals. In rodents, central or peripheral injection of ghrelin increases feeding behavior  stimulates feeding behavior, whereas a higher dose (2.4 nmol/100 g body weight) suppresses feeding behavior in adult Japanese quail  have been identified. In mammals, the melanocortin system plays an important role in regulating food intake and energy metabolism because disrupting melanocortin receptor-4 (MC4R) results in obesity, hyperphagia, and hyperglycemia in mice , and others. In the pancreatic peptide family, NPY, pancreatic polypeptide (PP), and peptide YY (PYY) are thought to be orexigenic peptides in birds , motilin, and orexin are also known as orexigenic peptides  and PYY(3-36). ICV injection of PYY(1-36) stimulates feeding behavior in rats  and κ-receptor agonists (U-50488H and U-62066) increase food intake in chicks , a 17-amino acid peptide, is an endogenous ligand of the nociceptin receptor, which shows structural similarity to the opioid receptor. Nociceptin is thought to have an orexigenic effect in mammals  , an ortholog of PrRP, was isolated from Japanese crucian carp (Fujimoto et al., PrRP was first isolated from the hypothalamus as a specific prolactin-releasing factor for mammalian pituitary cells (Hinuma et al., Somatostatin is well-known as a hypothalamic inhibitor of GH release from the anterior pituitary (Brazeau et al., As noted above, it is likely that the effects of GH-related peptides including ghrelin and GHRH are different between chicks and mammals. In mammals, peptides that stimulate GH release usually show an orexigenic effect, whereas peptides that inhibit GH release partly have an anorexigenic effect. In chicks, on the other hand, GHRH and ghrelin possess an anorexigenic effect, whereas somatostatin possesses an orexigenic effect. Because most of these studies were performed by injecting exogenous peptides, further studies on the effect of endogenous GH-related peptides should show the actual relationship between these peptides and feeding behavior in chicks.Galanin is a neuropeptide consisting of 29-amino acids and is distributed in the brain and digestive tract. Central injection of galanin stimulates feeding behavior in rats (Kyrkouli et al., As noted above, several kinds of peptidergic molecules are related to the regulation of feeding behavior in birds, and some neuropeptides show different effects from that in other vertebrates. Notably, non-peptidergic feeding regulatory factors, such as norepinephrine, 5-hydroxytryptamine, and histamine, show a similar effect in vertebrates when administered centrally (Denbow et al., However, most of the studies on feeding regulation in birds have used exogenous peptide treatments. Studies on the roles of endogenous feeding regulatory peptides are needed to understand the true physiological regulation of feeding behavior in birds. In addition, it should be noted that most of the studies used neonatal and young chickens. It is possible that the roles of neuropeptides in regulating feeding behavior vary with age. Studies using adult birds should clarify the actual difference in neuropeptide control of feeding behavior between vertebrates. Clarifying the feeding regulatory mechanism should provide information on the evolution of feeding regulation in vertebrates and would be beneficial information for poultry production.TT wrote this review together with co-author KT, Waseda University, Japan. In addition, TT integrated KT's sentences and edited this review as the corresponding author.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.


Size-exclusion chromatography (SEC) coupled to small-angle X-ray scattering (SAXS), also known as inline SEC-SAXS, is being increasingly used for the structural analysis of biological macromolecules, complexes and mixtures in solution. A single SEC-SAXS run generates thousands of individual SAXS profiles from the eluting solute and their analysis requires a correct identification of buffer and sample regions, a rather laborous task. We present CHROMIXS (as in CHROMatography Inline X-ray Scattering), a program for rapid reduction and analysis, both automatically and interactively, of SEC-SAXS data.www.embl-hamburg.de/biosaxs/download.html).CHROMIXS is freely available to academic users as part of the ATSAS software suite ( Using ag) and molecular weight values, with options to export both raw data and scalable vector graphics (SVG) for the preparation of publication quality figures , a user-friendly tool that allows rapid visualization and reduction, both automatically and interactively, of SEC-SAXS datasets. CHROMIXS streamlines the work of expert users and it also allows non-experts to quickly evaluate the results of a SEC-SAXS run. Importantly, CHROMIXS can work fully unsupervised in automatic mode, identifying sample and buffer regions from the elution profile to produce a final subtracted SAXS curve. The graphical interface provides additional functionality, such as automatic estimation of the radius of gyration  as shown in . By defaThe user can define sample and buffer regions using the mouse through CHROMIXS’ graphical interface. Commonly, the sample region corresponds to the tip of the elution peak of interest, while matching buffer is expected to elute in the flat region just before the sample begins to elute. Alternatively, CHROMIXS’ automatic sample prediction function can be called, which is a peak-finder implementation based on the derivatives of the elution profile curve adjusted by the initial noise estimation.N consecutive frames (the same number as in the selected sample) to find low intensity and continuous regions in the elution profile. Each putative buffer region found is subtracted from the sample signal and the subtracted curves are scored using the ‘quality’ measure of the autorg ATSAS routine . The region with the best quality score after subtraction is selected as the optimal buffer region.Once a sample region has been defined, a buffer region may be selected manually or automatically. The automatic buffer prediction procedure uses an average over a sliding window of Once the buffer and sample regions have been defined, single buffer frames are subtracted from sample frames one by one, scaled and averaged to produce the final subtracted curve. This approach allows for statistically rigorous estimation and propagation of the associated errors (manuscript in preparation).g values estimated by CHROMIXS can also be exported as raw data in CSV format, for customized plotting or treatment. Alternatively, data can be saved in CHROMIXS’ native format, to continue the analysis later. The users can also utilize the ‘open selected frames in Primus’ menu to redirect selected buffer or sample frames to PRIMUS/qt program for the detailed analysis of individual frames, including statistical comparisons  and buffer regions and produces subtracted curve(s). Details of the selection and results are written as metadata in the output file for future reference. An automatic reduction of a bovine serum albumin (BSA) SEC-SAXS dataset consisting of 1800 SAXS one-dimensional frames  takes a BioXTAS RAW . In more intricate cases, CHROMIXS may help in diagnosing and preparing the data for further processing by other programs . For example, overlapping peaks may be decomposed by Currently, CHROMIXS is being routinely used at the EMBL Hamburg P12 BioSAXS beamline, where an increasing percentage of measurements are performed in SEC-SAXS mode. CHROMIXS reads plain ASCII files in and it was tested on the experimental data generated by other SAXS beamlines . In addition to a fully automatic SEC-SAXS processing function, CHROMIXS provides a responsive and easy-to-use interface, optimal errors propagation and experiment quality assessment together with thorough data and figure export features.


Managing landscape connectivity is a widely recognized overarching strategy for conserving biodiversity in human-impacted landscapes. However, planning the conservation and management of landscape connectivity of multiple and ecologically distinct species is still challenging. Here we provide a spatially-explicit framework which identifies and prioritizes connectivity conservation and restoration actions for species with distinct habitat affinities. Specifically, our study system comprised three groups of common bird species, forest-specialists, farmland-specialists, and generalists, populating a highly heterogeneous agricultural countryside in the southwestern Iberian Peninsula. We first performed a comprehensive analysis of the environmental variables underlying the distributional patterns of each bird species to reveal generalities in their guild-specific responses to landscape structure. Then, we identified sites which could be considered pivotal in maintaining current levels of landscape connectivity for the three bird guilds simultaneously, as well as the number and location of sites that need to be restored to maximize connectivity levels. Interestingly, we found that a small number of sites defined the shortest connectivity paths for the three bird guilds simultaneously, and were therefore considered key for conservation. Moreover, an even smaller number of sites were identified as critical to expand the landscape connectivity at maximum for the regional bird assemblage as a whole. Our spatially-explicit framework can provide valuable decision-making support to conservation practitioners aiming to identify key connectivity and restoration sites, a particularly urgent task in rapidly changing landscapes such as agroecosystems. This issensu ), is thesensu . Howeversensu –9.Inferring landscape connectivity requires a thorough knowledge of how organisms perceive a certain landscape and how they respond to changes in its structural properties ,11. BecaHere, we performed an analysis of landscape connectivity for species with distinct habitat affinities with the aim of providing a spatially-explicit framework that prioritizes connectivity conservation and restoration actions. We focused on three groups of common bird species, forest-specialists, farmland-specialists, and generalists, populating a highly heterogeneous agricultural countryside in the southwestern Iberian Peninsula. We first performed a detailed analysis of the landscape-related mechanisms underlying the distributional patterns of each bird species to uncover generalities in their guild-specific response to landscape structure . Then, uca. 426,000 hectares (Quercus suber L.) and holm-oak (Q. rotundifolia L.) at varying densities, comprising the characteristic Portuguese montado, a High Nature Value Farming System according to the classification of the European Environmental Agency ([Olea europaea L.) and vineyards (Vitis spp.), and timber plantations , all of which are interspersed with small human settlements, roads and wetlands , in a study area of  Agency . Rather than rectangular or square grids, we used hexagonal cells (henceforth referred to as ‘cells’) as they have been shown to be particularly suitable in spatially-complex landscapes . We usedn > 200), we first integrated the land-cover types into six groups: (i) forests, including all types of natural woodlands such as montado), (ii) open agricultural areas, including extensive cereal farming and cleared forest areas used for cattle grazing, (iii) pine and eucalyptus plantations as well as and tree-like crops such as olive orchards and vineyards, (iv) urbanized areas, including urban and industrial areas, (v) transportation infrastructures such as roads and railroad tracks and (vi) water bodies, including reservoirs, rivers and watering holes.We characterized the landscape using land-cover data from CORINE Land-cover (CLCN5), the most detailed and highest resolution  database available for continental Portugal . Becausek-means clustering algorithm [The regional landscape was characterized using both composition and configuration metrics , 24. Lanlgorithm . We idenLandscape configuration was also varied but fell into two distinct classes: homogeneous and heterogeneous cells. Homogeneous cells were characterized by large, scarce and close patches of dominant land-cover types (Configuration class 1). Heterogeneous cells were characterized by a high diversity of small and dispersed land-cover types (Configuration class 2). See Birds were sampled during the 2013 breeding season (April–May) in a total of 162 cells. Field surveys did not involve endangered or protected species. Sampling surveys were reviewed and approved by the Institute for Nature and Forest Conservation . To adequately sample birds across the complete range of structural complexity of the study area, we selected cells corresponding to each type of landscape unit while accounting for their representativeness throughout the regional landscape. Since landscape patterns are commonly locally-aggregated, a robust sampling design was essential to reach a comprehensive understanding of the influence of landscape structure on species distribution . SamplinSampling consisted of 10-minute point counts where the presence of every bird visually observed or heard within a radius of 100 m (~3.14 ha) was recorded. Any sign of breeding activity  was also recorded. Birds were sampled once at the center of each selected cell in sessions that began just after sunrise and concluded no later than 10:00 a.m. to avoid the central hours of the day when bird activity is at its minimum in the study region . Based oFinally, every cell was classified as either suitable, passage or unsuitable for each guild by comparing the observed frequency distribution of species across landscape units to the expected values derived from the relative frequency of each landscape unit in the study region . A landsMulTyLink [MulTyLink is particularly suitable for our purposes because it is specifically designed to retrieve efficient linkages for species or group of species with distinct ecological requirements. Thus, when selecting areas for a given species or group of species in a graph, MulTyLink considers the possibility of using these selected areas for other species (or group of species), thus reducing linkage cost (e.g. in terms of length or area) [ci = 1), and that for suitable landscape units as zero (ci = 0). It should be mentioned that, with no detailed information on the differential impacts of different passage areas for each species group, we chose to define costs homogeneously for those areas. Moreover, the costs defined for unsuitable areas assume that they may be passage areas for some species groups, and therefore, the same assumption applies. In this way solutions are insensible to the particular value of costs. In this way, the optimization process to determine cost-efficient connectivity linkages between environmentally suitable areas, thus operated on the basis of minimizing the amount of passage areas (i.e. number of cells selected), while fixing (at no cost) the suitable habitats for the three species groups. It is worth noting that because MulTyLink was developed to operate using a network of square cells, our hexagonal cells were transformed into square cells  . Here, tGrasp (Greedy Randomized Adaptive Search Procedure) algorithm from MulTyLink [First, we conducted the connectivity analysis to determine the cells critical to maintaining current landscape connectivity, henceforth referred as key conservation cells. To perform this analysis, we obtained corridors for each individual guild using the ulTyLink , 41. ThiMulTyLink 100 times over a simulated landscape where these cells were degraded into unsuitable habitats for all three bird guilds  within the landscape. These comparisons were made by starting with nr equal to the number of key restoration cells and then adding or subtracting three cells at a time.The second approach to our connectivity analysis consisted of a spatially-explicit prioritization exercise aimed to determine those cells that, if restored, would maximize landscape connectivity for the three individual guilds while ensuring the shortest movements for the whole bird assemblage. Thus, we simulated the impact on connectivity metrics of converting, for example, homogeneous tree plantations to heterogeneous forests or mixed habitats . All theEmberiza calandra; Passer hispaniolensis , the common chaffinch Fringilla coelebs  and the Eurasian blue tit   and Fringilla coelebs , as well as the short-toed tree-creeper Certhia brachydactyla , were also among the species occurring in a higher number of cells  . Both Cyof cells .The proportion of cells classified as suitable throughout the study region was similar among bird guilds  . The proThe approach we used to determine landscape suitability for different bird species was able to identify biologically meaningful relationships between land-cover and bird guilds. Homogeneously forested cells , for example, were identified as suitable landscape units for forest-specialist species, but not for farmland specialists . Only stTotal connected area as estimated by the number of connected cells was 1.5 times higher for generalist species than for farmland- or forest-specialist species . The degA total of 46 cells  were selected in all 100 model replicates of movement linkage for each of the three bird guilds simultaneously, and were thus considered to be key conservation cells . They weBoth total connected area and number of clusters reached an asymptote when a total of 15 cells (975 ha) were restored from unsuitable to passage landscape units . Each ofWe describe a restoration-prioritization methodology that integrates both spatial-graphs and landscape suitability models, able to evaluate the impact of degrading and/or restoring key connectivity areas for multiple and ecologically distinct species. In doing so, we first investigated the landscape-related mechanisms underlying the spatial patterning of species distribution to infer guild-based landscape suitability for bird species. This landscape suitability was then used as a measure of resistance to movement. By using a spatially explicit approach, we finally identified priority sites as well as both the number and spatial location of sites that should be restored to significantly increase landscape connectivity for the regional bird community as a whole. Our approach provides valuable support to conservation practitioners in the decision-making process to identify key connectivity and restoration zones, a particularly challenging task in rapidly changing landscapes such as agroecosystems , 43.sensu [Most research aiming to infer landscape connectivity from resistance values computed by landscape characteristics have assumed that the availability of preferred land-cover type plays an essential (and often exclusive) role in shaping the spatial distribution patterns of species , 45. Nevsensu ) which usensu . Becausesensu .montado [As expected, we found that homogeneously forested sites were suitable for forest-specialist bird species, but unsuitable for farmland-specialists. Interestingly, however, heterogeneous strictly forest cells were identified as passage habitats not only for forest specialists but also for farmland-specialists. This might be explained by the fact that heterogeneous strictly forest areas in our study region are typically savanna-like forests with varying densities of trees (the characteristic Portuguese montado ), resultmontado ,49. In tmontado –52. Indemontado , 46.n = 15 cells) was identified as a priority for restoration to minimize fragmentation for the three bird guilds studied. From a management perspective, habitat restoration in these areas would permit maximum landscape connectivity at minimum cost.The new approach we present here provides a spatially-explicit framework which identifies and prioritizes connectivity conservation and restoration actions for species with distinct habitat affinities. This is possible because (1) it incorporates landscape suitability and connectivity requirements for each single species or a group of species, (2) it enables the identification of priority sites for the maintenance of current landscape connectivity (i.e. key conservation sites), and (3) it identifies sites whose restoration would permit maximum landscape connectivity. Most distribution-oriented approaches to support landscape connectivity for multiple species rely on the identification of focal or umbrella species , 48, 49.S1 Table(ODT)Click here for additional data file.S2 Table(XLS)Click here for additional data file.S1 Fig(DOC)Click here for additional data file.