Understanding the main processes that affect community similarity have been the focus of much ecological research. However, the relative effects of environmental and spatial aspects in structuring ecological communities is still unresolved and is probably scale-dependent. Here, we examine the effect of habitat identity and spatial distance on fine-grained community similarity within a biogeographic transition zone. We compared four hypotheses: i) habitat identity alone, ii) spatial proximity alone, iii) non-interactive effects of both habitat identity and spatial proximity, and iv) interactive effect of habitat identity and spatial proximity. We explored these hypotheses for spiders in three fragmented landscapes located along the sharp climatic gradient of Southern Judea Lowlands (SJL), Israel. We sampled 14,854 spiders (from 199 species or morphospecies) in 644 samples, taken in 35 patches and stratified to nine different habitats. We calculated the Bray-Curtis similarity between all samples-pairs. We divided the pairwise values to four functional distance categories  and two habitat categories (same or different habitats) and compared them using non-parametric MANOVA. A significant interaction between habitat identity and spatial distance was found, such that the difference in mean similarity between same-habitat pairs and different-habitat pairs decreases with spatial distance. Additionally, community similarity decayed with spatial distance. Furthermore, at all distances, same-habitat pairs had higher similarity than different-habitats pairs. Our results support the fourth hypothesis of interactive effect of habitat identity and spatial proximity. We suggest that the environmental complexity of habitats or increased habitat specificity of species near the edge of their distribution range may explain this pattern. Thus, in transitions zones care should be taken when using habitats as surrogate of community composition in conservation planning since similar habitats in different locations are more likely to support different communities. Disentangling the effects of niche-based and dispersal-based processes in structuring ecological communities have challenged ecologists for the last few decades , 2. AlthAs a consequence, both niche-based processes and dispersal-based processes affect the similarity in community composition between two samples  taken at a certain spatial distance from one another. In fact, Chase and Myers (2011)  suggesteHowever, exploring the distance-decay of similarity at small-grain sizes is not straight-forward for several reasons. Firstly, Nekola and White 1999)  reported99  repora) from the same patch; b) from different patches but from the same landscape ; c) two samples from adjacent landscapes ; and d) two samples from distant landscapes . Similarly, environmental distance can be categorized at the local scale according to habitat identity with two samples from the same habitat or from different habitats. Exploring the change in community composition based on such spatial and environmental distance categories may allow testing four general hypotheses:Here we approach this complexity by moving from continuous spatial and environmental distances to ecologically-defined categories. The categories of the spatial distance can be based on well-defined, natural hierarchical structure in the distribution of natural habitats. For example, two samples can be Habitat identity alone—if community composition is affected mainly by niche-based processes, pairs of samples from the same habitat will exhibit higher levels of similarity than pairs of samples from different habitats and similarity should not differ considerably between the different distance categories.Spatial proximity alone—if community composition is affected mainly by dispersal-based processes, the mean pairwise similarity should decrease from distance category a to d with no difference between pairs of samples from the same habitat and pairs of samples from different habitats at any distance category.Non-interactive effect of both habitat identity and spatial proximity–if community composition is affected independently by niche-based and dispersal-based processes, similarity should decay with distance and be higher at same habitat pairs. However, the difference between the same habitat pairs and different habitat pairs should be similar at all distance categories.Interactive effect of habitat identity and spatial proximity–if community composition is affected by both niche-based and dispersal-based processes, yet the two sets of processes interact, similarity should decay with distance and be higher at same habitat pairs. In this case, the difference between same habitat pairs and different habitat pairs should decrease with distance.Despite the simplicity of the above hypotheses, we are not aware of any publications that actually explored them. Thus, in addition to understanding what processes could affect decay similarity in our spider communities, one of the goals of this paper is to produce a simple procedure to disentangle the effects of dispersal-based vs. niche-based processes in scale-dependent systems. More specifically, we explore here the above four hypotheses using fine-scale samples of spiders along a 30 km sharp climatic gradient in Southern Judea Lowlands (SJL), Israel . SJL offWe focused our sampling in SJL, Israel . We usedAsphodelus ramosus), Sarcopoterium spinosum, Hyparrhenia hirta, shrubs , bushes , and thistles (mainly Silybum marianum and Notobasis syriaca). The nine habitats can be divided to two main groups that differ considerably in various environmental aspects. The first group is more environmentally simple and contain the first four habitats. The second group is more environmentally complex and contain the remaining five habitats. Among others, the group of complex habitats are more structurally complex, have considerably higher plant biomass, have higher abundance and diversity of potential prey and provide more shade in the hot days of the summer, when temperatures can rise to 45°Celsius. This separation was based on close knowledge of our system and clear familiarity with the focal group of organisms. However, we also confirmed this separation by explicitly analysing and comparing the different habitats (see below).We sampled 13 patches in each of the south and middle landscapes and 9 patches in the north landscape. Sampling was stratified according to nine a-priori defined habitats  and contained a single habitat. We ensured sampling at least one quadrat from each complex habitat we observed in each patch, because preliminary sampling revealed that spider abundance and species richness in the complex habitats was significantly higher than in the simple ones. Each patch contained ≥7 quadrats and sampling effort increased with patch size. A total of 216, 230 and 198 samples containing spiders were taken in the south, middle and north landscapes, respectively. Additional 57 samples  did not contain any spiders and were excluded from all analyses.To obtain samples, we used the vacuum option of a leaf blower with a mesh (0.5 mm) sleeve inserted within the suction tube . For annmetaMDS function in the vegan package ).Similarly, the strong effects of habitat identity on spider composition similarity at small distances is not surprising, given spiders’ sensitivity to habitats’ structural complexity, prey availability and microclimate conditions , 42–44. However, our analysis revealed significant differences between same and different habitat pairs even at the largest distance category. One explanation is that the difference for the distant landscapes category in Another explanation for the observed difference at large distance categories is that, despite a relatively high turnover rate, still a large enough number of species were found in all three landscapes, and that for these species the entire SJL lies at the edge of their global distribution pattern. In fact, the 86 spider species found in all three landscapes represent 58%, 60% and 72% of the total species recorded in the south, middle, and north landscapes, respectively. Species near the edge of their distribution range are expected to become more specific in their habitat requirements . EmpiricThe relative effect of spatial proximity and habitat identity was examined in the North American transition zone between shortgrass-steppe and Chihuahuan desert for several arthropod taxa, including ants , cricketWe argue that habitat identity may countervail the effect of distance, as long as the species pool is relatively homogeneous. In transition zones between biogeographic species pools, such as the SJL and the North American shortgrass-steppe to desert transition zone , 52, theAs it is practically impossible to tailor-suit a conservation plan for every species, habitats are commonly used as surrogates in conservation planning. By knowing the community composition of different habitats, alternative conservation plans can be compared based on the complementarity of the species conserved . Our resS1 Fig(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S1 Table(CSV)Click here for additional data file.


These children were at greatest risk of being obese and aerobically unfit (p < 0.01). Our results suggest that deprivation may explain the counterintuitive relationship between obesity, CRF and ASC in Liverpool schoolchildren. These findings encourage researchers and policy makers to be equally mindful of the social determinants of health when advocating behavioral and environmental health interventions. Further research exploring contextual factors to ASC, and examining the concurrent effect of ASC and diet on weight status by deprivation is needed.This study investigated differences in health outcomes between active and passive school commuters, and examined associations between parent perceptions of the neighborhood environment and active school commuting (ASC). One hundred-ninety-four children (107 girls), aged 9–10 years from ten primary schools in Liverpool, England, participated in this cross-sectional study. Measures of stature, body mass, waist circumference and cardiorespiratory fitness (CRF) were taken. School commute mode (active/passive) was self-reported and parents completed the neighborhood environment walkability scale for youth. Fifty-three percent of children commuted to school actively. Schoolchildren who lived in more deprived neighborhoods perceived by parents as being highly connected, unaesthetic and having mixed land-use were more likely to commute to school actively ( Childhood obesity and poor health are most prevalent in areas of high deprivation ,2,3. PhyIn recent years, there has been an increasing focus by the UK government to promote and increase ASC among schoolchildren with a view to curbing rising obesity levels . HoweverASC is influenced by multiple environmental factors. Household distance to school is considered the strongest influence with shorter distances associated with higher levels of ASC ,25,26. Hn = 326) in participating schools received a participant recruitment pack containing parent and child information sheets, consent and assent forms, and a medical screening form. Written informed consent and assent were received from parents and their children, respectively, before children could participate in the study. Completed informed parental consent and child assent were obtained for 217 children (39.5% response rate). Liverpool John Moores University Ethics Committee approved the study (13/SPS/048) and data collection took place between January and April 2014.Study participants were 9–10 years-old schoolchildren recruited from ten primary schools in Liverpool, England. Liverpool is ranked the most deprived English city  and obes2) and BMI z-scores were assigned to each child  to actively commute more to improve their weight status, we suggest that the challenge remains to identify ways to reduce deprivation, and increase ASC prevalence among the nonparticipants, especially those that live in close proximity to school. A recent UK study  explorinactual commute distance taken for all children. Another limitation is the fact that some children can be driven to school in the morning but commute actively in the afternoon. However, we did not distinguish between active, passive or ‘mixed transport’ commuters. Despite these limitations, the findings reported here are consistent with larger-scale studies [This is the first study to explore the influence of neighborhood attributes on schoolchildren’s ASC using the NEWS-Y survey. Several limitations are though, worthy of consideration. Our study used cross-sectional data, which limits inference of causality. When compared with the national average, children in this study lived in more deprived areas and had higher BMI. Therefore, generalizing our findings to more affluent and rural areas of the UK should be done with caution. The NEWS-Y survey is a valid and reliable measure of neighborhood attributes  but may  studies ,18.In this study, schoolchildren who lived in more-deprived neighborhoods perceived by parents as being highly connected, unaesthetic and having mixed land-use were more likely to commute to school actively. These children were at greatest risk of being obese and aerobically unfit. Our findings suggest that deprivation may explain the counterintuitive relationship between obesity, cardiorespiratory fitness (CRF) and active school commuting (ASC) in Liverpool schoolchildren. These findings encourage researchers and policy makers to be mindful of the social determinants of health when planning and advocating behavioral and environmental health interventions. Further research exploring contextual factors to ASC, and examining the concurrent effects of ASC and diet on weight status by deprivation is needed. To improve child health and alleviate deprivation requires a systems approach to health promotion and actions on inequalities in wider social determinants operating outside the health system.


Salmonella are Gram-negative rod-shaped facultative anaerobic bacteria that are comprised of over 2,000 serovars. They cause gastroenteritis  with headache, abdominal pain and diarrhea clinical symptoms. Salmonellosis brings a heavy burden for the public health in both developing and developed countries. Antibiotics are usually effective in treating the infected patients with severe gastroenteritis, although antibiotic resistance is on the rise. Understanding the molecular mechanisms of Salmonella infection is vital to combat the disease. In vitro immortalized 2-D cell lines, ex vivo tissues/organs and several animal models have been successfully utilized to study Salmonella infections. Although these infection models have contributed to uncovering the molecular virulence mechanisms, some intrinsic shortcomings have limited their wider applications. Notably, cell lines only contain a single cell type, which cannot reproduce some of the hallmarks of natural infections. While ex vivo tissues/organs alleviate some of these concerns, they are more difficult to maintain, in particular for long term experiments. In addition, non-human animal models are known to reflect only part of the human disease process. Enteroids and induced intestinal organoids are emerging as effective infection models due to their closeness in mimicking the infected tissues/organs. Induced intestinal organoids are derived from iPSCs and contain mesenchymal cells whereas enteroids are derive from intestinal stem cells and are comprised of epithelial cells only. Both enteroids and induced intestinal organoids mimic the villus and crypt domains comparable to the architectures of the in vivo intestine. We review here that enteroids and induced intestinal organoids are emerging as desired infection models to study bacterial-host interactions of Salmonella. Salmonella are Gram-negative rod-shaped and facultative anaerobes belong to the family of Enterobacteriaceae  is treated as a separate species due to its unique clinical features , salamae (II), arizonae (IIIa), diarizonae (IIIb), houtenae (IV), and indica (VI), mainly based on their genomic sequence and biochemical properties , capsular (K), and flagellar (H) antigenic determinants  based on the clinical patterns in human salmonellosis , followed by the onset of fever, which might sustain an incubation period of 1 week or more , while NTS strains have a broader host-range and represent zoonotic features  and Serovar Enteritidis, which are common even in developed countries  and flagella (H). The enzyme-linked immunosorbent assays (ELISAs) and sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) immunoblotting assays are useful in measuring antibodies in patients' sera. Recently, PCR, real-time PCR, and proteomic approaches have been used to analyze bacterial genes and proteins  is the best studied one. It is located at centisome 63 on the Salmonella chromosome and is 43-kb in length. SPI1 is required for Salmonella entry into M cells  is also involved in the Salmonella invasion process . The translocation of these bacterial proteins into eukaryotic host cells is required for Salmonella invasion into non-phagocytic epithelial cells. Secretion has been reported to require host-cell contact  one includes genes that encode the actual secretion/translocation apparatus; (2) a second group encodes proteins that are secreted and/or translocated into host cells; (3) a third group involves in gene regulation. The SPI1 secretion apparatus was shown by electron microscopy  bile acid resistance is responsible for conferring a fitness advantage during luminal growth in the inflamed intestine  including Trg, Tsr, and Aer, were identified to enhance the fitness of Salmonella in a mouse colitis model  model  near the bottom of the intestinal crypts , or single intestinal stem cells by formation of budding crypts . Meanwhile, induced intestinal organoids contain most cell types that are present in the human intestine  with villi domain and crypt domain  under specific culture conditions  as well as in the C57BL/6 mouse model upon Salmonella infection  induction together with elevated tumor necrosis factor alpha (TNF-α)  signaling pathway in the mouse enteroids accompanied by the expression of inflammatory cytokines including TNF-α and IFN-γ   and protein kinase B (PKB or AKT) pathways is responsible for the transformation. Importantly, the result from murine gallbladder organoids is in agreement with observations in GBC patients  cause foodborne diseases in both developing and industrialized countries , a Gram-positive obligate anaerobic bacteria ubiquitous in nature, infects the human colon in 2–5% of the adult population. Imbalance of the normal gut flora could increase the chances of Clostridium infection. The bacteria may produce diarrhea and inflammation in infected patients via the well characterized enterotoxin (C. difficile toxin A) and cytotoxin (C. difficile toxin B). IHIOs derived from human pluripotent stem cells were used to study C. difficile and the contribution of toxins. It was shown that the toxins played a major role in the colonization and disruption of the iHIO epithelium, and in the loss of the paracellular barrier function  colonization of the human stomach has been associated with chronic gastritis, ulceration, and adenocarcinoma. To study the pathogenesis of H. pylori infection, human gastric organoids were generated from surgical samples of human gastric corpus. The gastric organoids displayed the typical characteristics of their corresponding tissues, based on their histology, expression of markers, and euploidy , Irinotecan, Oxaliplatin, Doxorubicin, and Paclitaxel on peritoneal metastases using enteroids (Roy et al., Salmonellosis remains a major public health concern globally. The availability of various infection models has helped to identify bacterial virulence factors responsible for causing the diseases. Studies utilizing these infection models have advanced our understanding of how pathogens deploy their virulence factors to modulate host cell functions during infection. Classical infection models include various 2-D cultures of immortalized cells and animal models. Recent advances in stem cell research have helped to establish organoids and enteroids as viable alternatives to many established infection models. We anticipate that organoids and enteroid infection models will play a key role in advancing out understanding in antimicrobial drug screening, personalized medicine, virulence mechanisms and pathogen-host interactions.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Progressive multifocal leukoencephalopathy (PML) is a rare disease of the immunosuppression that results from neurotropic invasion of the JC virus which leads to demyelination of oligodendrocytes. Immune reconstitution inflammatory syndrome (IRIS), on the other hand, is a condition of inflammation that develops as the immune system reconstitutes. This case report describes a case of a 35-year-old HIV-negative male who presented with three weeks of right lower extremity paresthesias as well as right upper extremity apraxia. He was diagnosed with PML complicated by IRIS secondary to Rituximab, which he had completed four months prior to presentation. Despite the condition's poor prognosis, the patient recovered with only minor deficits. Progressive multifocal leukoencephalopathy (PML) is a rare disease resulting from the neurotropic invasion of the JC virus in the setting of immunosuppression . In patiA 35-year-old HIV- (human immunodeficiency virus-) negative male presented with three weeks of right lower extremity paresthesias and right upper extremity apraxia. His history was significant for Ann Arbor stage IV follicular lymphoma, in remission after initial Bendamustine and Rituximab, followed by maintenance Rituximab completed four months earlier. Physical exam revealed right upper extremity apraxia and weakness. Head CT revealed new bifrontal multifocal white matter hypoattenuation, while MRI brain see  revealedThe JC virus is mostly acquired during childhood or adolescence and remains in various organs including kidneys, bone marrow, and lymphoid tissue . In the While the development of immune reconstitution is essential for clearance of JC virus and recovery from PML, IRIS can occur as a complication of immune reconstitution leading to possible death. While guidelines for diagnosis exist in HIV-positive patients undergoing therapy, the diverse clinical presentation prevents strict diagnostic criteria for both HIV-positive and HIV-negative patients. Furthermore, there are no specific tests to establish an IRIS diagnosis. In IRIS, gadolinium enhancement on MRI, an atypical finding in PML, in association with worsening neurologic symptoms, can aid in diagnosis. While use of glucocorticoids is currently the common treatment, little benefit has been proven and steroids can potentially limit JC viral clearance. PML may be more prevalent in patients with low CD4 counts; however once again after expert consultation use of IL-7 was deferred since the patient's CD4 count was >200. The benefit of Maraviroc in preventing further complications of IRIS through the inhibition of CC5 dependent immune trafficking into the central nervous system has been noted in case reports. Our patient did not benefit from steroids or Maraviroc [In conclusion, the development of IRIS that cleared the CSF of JC virus despite the patient's poor prognosis, related to hematologic malignancy and Rituximab-associated disease, makes his case unique . His imp


Identifying which individuals benefit most from particular treatments or other interventions underpins so-called personalised or stratified medicine. However, single trials are typically underpowered for exploring whether participant characteristics, such as age or disease severity, determine an individual’s response to treatment. A meta-analysis of multiple trials, particularly one where individual participant data (IPD) are available, provides greater power to investigate interactions between participant characteristics (covariates) and treatment effects. We use a published IPD meta-analysis to illustrate three broad approaches used for testing such interactions. Based on another systematic review of recently published IPD meta-analyses, we also show that all three approaches can be applied to aggregate data as well as IPD. We also summarise which methods of analysing and presenting interactions are in current use, and describe their advantages and disadvantages. We recommend that testing for interactions using within-trials information alone (the deft approach) becomes standard practice, alongside graphical presentation that directly visualises this. Meta-analysis of participant level treatment-covariate interactions raises additional complications that do not affect either standard meta-analysis or single trial interaction analysis alone. These complications are often overlooked by reviewers. The issues are independent of other aspects of meta-analysis, such as the choice of one stage or two stage model fitting, or whether aggregate data or individual participant data (IPD)Meta-analysis is often the only way to reliably detect whether treatment benefit differs between groups of participants—that is, to detect interactions between treatment efficacy and participant characteristicsOf three general approaches, we advocate the deft approach, which avoids the risk of ecological bias over the deluded and daft approaches, which do notA systematic review of recently published meta-analyses of individual participant data shows that 89% of interaction analyses either used a deluded method (23%), or did not report sufficient details (66%) to tell which approach had been used. Further, graphical presentation often hindered appreciation of key data featuresThese findings indicate poor appreciation of analysis and reporting issues surrounding interactions in the research communityWhere suitable data were reported in published systematic reviews, reanalysis showed that use of the different approaches can yield inconsistent resultsTesting for interactions using deft methods, and using a graphical presentation that directly visualises this, should become standard practiceOur illustrative example is a systematic review and IPD meta-analysis relating to the care of patients with acute stroke, which compared a strategy of early supported hospital discharge (ESD) to conventional hospital services and discharge arrangements.v standard care) for each trial against the proportion of trial participants who had a carer present. Fitting a meta-regressionThis approach can be visualised by plotting the mean difference in the length of hospital stay .This approach is presented in figure 12=45%)) among the interaction estimates, suggesting that presence of a carer might not be a wholly reliable indicator of ESD efficacy. Appropriately, the Montreal trial is not included in this deft analysis, because a within-trial interaction is not estimable.This approach adheres to the underlying principles of meta-analysis by assessing the effect of interest as measured within each relevant trial. The left panel in figure 2Having highlighted what is at stake, we present the results of our systematic review of the literature. We searched Medline (2011-14) for IPD meta-analyses of treatment efficacy that included at least one investigation of interaction between treatment and a participant level covariate (web appendix A). Our search returned 184 unique results, of which 80 were eligible. However, one ineligible study cited two additional IPD meta-analyses, giving a total of 82 eligible results. Table 1, deluded, or deft analysis was carried out. This includes both so-called one stage modelling approaches ,ordeft,Efforts to advocate a deft approachThe majority of reviews (56% of 82) tested for interaction exclusively by calculating the treatment difference between just two participant level subgroups, even where the underlying data were continuous or ordinal. Such collapsing of data is known to be suboptimal, both in terms of power and bias, as well as biologically implausible.In our sample, other than presenting no plot at all (34% of reviews), the most common presentational approach (43%) by far was to present summary treatment effects within each covariate subgroup  is itself a demonstration that aggregate data, albeit in this case derived from IPD, can be analysed by any approach. Our results suggest that, in practice, only deluded or deft analyses are used. However, deluded analyses combine information from daft and deft analyses, which we found to be poorly correlated (fig 2v 6%).Six meta-analyses from our reviewWe next made a descriptive assessment of levels of agreement between effect estimates from deluded and deft analyses.Poor reporting and presentation, particularly when combined with inappropriate methods, is a key shortcoming of interaction analyses. Given that a deft analysis is at the least risk of bias, and can be clearly presented and readily interpreted, it should be the preferred approach for assessing participant level interactions aimed at influencing clinical practice. This can be achieved . Hence, although a deluded approach might have a role in exploratory analyses or hypothesis generation, we strongly recommend that this intention be made explicit. Moreover, in such cases, within-trial, across-trial, and combined interactions should be presented separately so that readers will not be deluded. Rather, they can make their own judgments about the usefulness or otherwise of the daft estimate.However, within-trial (deft) identification of interactions is relatively rare,The two stage approach we recommend here has been criticised for being overly simple, inflexible, and possibly underpowered. Certainly, one stage models fitted to the entire dataset simultaneously allow for greater complexity; but an assessment of their relative power is confounded by their ability to produce either deluded or deft results depending on the separation of within-trial and across-trial effects.Our example (fig 1Investigating associations between the effects of treatments or other interventions and participant level covariates can help identify who is most likely to benefit, and allow treatments to be targeted appropriately. In an era when such investigations are increasingly common, deft analysis and presentation should be the recommended approach for reliably informing clinical practice.


Clinical decision makings according studies result require the valid and correct data collection, andanalysis. However, there are some common methodological and statistical issues which may ignore by authors. In individual matched case- control design bias arising from the unconditional analysis instead of conditional analysis. Using an unconditional logistic for matched data causes the imposition of a large number of nuisance parameters which may result in seriously biased estimates. Dear Editor:International Journal of Emergency Medicine [We read with interest, the article entitled “Blood product transfusion in emergency department patients: a case-control study of practice patterns and impact on outcome” by Beyer and colleagues published in Medicine . While wTo carry out this study, the authors used a matched case-control design and control subjects were matched with cases on a one-to-one basis for many factors including ED diagnosis, hemoglobin value, age, and gender, such that individual matching for all factors was assured. However, the authors analyzed the data inappropriately using a regression model. For individual matched case-control studies, we need to use conditional logistic modeling instead of the ordinary logistic regression methodology .In matched data, conditional logistic  analysis provides a valid approximation of the rate ratio and adjusts for the sampling variability found in estimating standard error and confidence intervals. Using an unconditional logistic for matched data causes the imposition of a large number of nuisance parameters which may result in seriously biased estimates . The tak


There is robust evidence that reasoning biases such as a tendency of jumping to conclusions (JTC) as well as cognitive deficits are associated with psychosis, but evidence on their association with affective disturbances remains inconclusive. Recent findings also suggest a transdiagnostic phenotype of co-occurring affective disturbances and psychotic experiences. This study aimed to investigate whether JTC bias and decreased working memory performance are associated with the co-occurrence of affective disturbances, psychotic experiences (PEs), and psychosis-related help-seeking behaviour (HS) in the general population.The second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2). Trained interviewers administered the Composite International Diagnostic Interview (CIDI) at three time points in a representative general population sample, with N=4.596 individuals who completed all assessments. The beads task and digit-span task were completed to assess JTC bias and working memory performance, respectively. CIDI was used to measure affective disturbances  and an add-on instrument to measure PEs and HS.We found that, compared to individuals with neither affective disturbances nor PEs, JTC bias was more likely to be present in individuals with co-occurring affective disturbances, PEs, and HS  in models adjusted for socio-demographic characteristics and socio-environmental factors. However, when we additionally adjusted for working memory performance this association was attenuated . In line with previous findings, there was no evidence that JTC bias was more likely to occur in individuals with sole presence of affective disturbances . Further, there was some evidence of a dose-response relationship, as JTC bias was progressively more likely to occur in individuals with affective disturbances as the level of PEs increased or HS was reported (high vs. moderate psychosis: p=0.052). In contrast, compared to individuals with neither affective disturbances nor PEs, a decreased working memory performance was evident in all groups .Our findings suggest that JTC bias and decreased working memory performance may contribute to a transdiagnostic phenotype of co-occurring affective disturbances and PEs. Further, findings support the notion that JTC bias may be specifically associated with psychosis, including in those presenting a transdiagnostic phenotype, while a lowered working memory performance may represent a more broadly distributed vulnerability factor across various symptom domains. Overall, results point to the need to further investigate whether established mechanism and risk factors, described to be involved in the development and maintenance of psychosis, extend to transdiagnostic phenotypes to further corroborate proposed aetiological models and overcome shortcomings of focussing only on specific domains of mental health.


Traumatic brain injury (TBI) is a multidimensional and highly complex disease commonly resulting in widespread injury to axons, due to rapid inertial acceleration/deceleration forces transmitted to the brain during impact. Axonal injury leads to brain network dysfunction, significantly contributing to cognitive and functional impairments frequently observed in TBI survivors. Diffuse axonal injury (DAI) is a clinical entity suggested by impaired level of consciousness and coma on clinical examination and characterized by widespread injury to the hemispheric white matter tracts, the corpus callosum and the brain stem. The clinical course of DAI is commonly unpredictable and it remains a challenging entity with limited therapeutic options, to date. Although axonal integrity may be disrupted at impact, the majority of axonal pathology evolves over time, resulting from delayed activation of complex intracellular biochemical cascades. Activation of these secondary biochemical pathways may lead to axonal transection, named secondary axotomy, and be responsible for the clinical decline of DAI patients. Advances in the neurocritical care of TBI patients have been achieved by refinements in multimodality monitoring for prevention and early detection of secondary injury factors, which can be applied also to DAI. There is an emerging role for biomarkers in blood, cerebrospinal fluid, and interstitial fluid using microdialysis in the evaluation of axonal injury in TBI. These biomarker studies have assessed various axonal and neuroglial markers as well as inflammatory mediators, such as cytokines and chemokines. Moreover, modern neuroimaging can detect subtle or overt DAI/white matter changes in diffuse TBI patients across all injury severities using magnetic resonance spectroscopy, diffusion tensor imaging, and positron emission tomography. Importantly, serial neuroimaging studies provide evidence for evolving axonal injury. Since axonal injury may be a key risk factor for neurodegeneration and dementias at long-term following TBI, the secondary injury processes may require prolonged monitoring. The aim of the present review is to summarize the clinical short- and long-term monitoring possibilities of axonal injury in TBI. Increased knowledge of the underlying pathophysiology achieved by advanced clinical monitoring raises hope for the development of novel treatment strategies for axonal injury in TBI. Traumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide –5. MortaAxonal injury was initially described by Strich in 1956, who observed diffuse axonal degeneration at autopsy of severe TBI patients . Axonal In the preclinical setting, the term traumatic axonal injury has been applied to describe axonal damage, with the term DAI used to express its clinical counterpart , 19. ThuIn this review, an overview of the current clinical possibilities for monitoring of DAI is provided. A literature search was performed in PubMed, Scopus and ISI Web of Knowledge. Experimental/preclinical studies on axonal injury in TBI were excluded from the overview with the exception of those describing key pathophysiological mechanisms. Articles where the injury type was not mentioned, was unclear or encompassing only focal TBI were also excluded from the analysis. Articles on mild, moderate, and/or severe TBI, DAI, and traumatic axonal injury were extracted, further screened and were included if the investigated mechanisms involved aspects of axonal/white matter injury. The literature on mild TBI, considered a diffuse TBI subtype with features of axonal and white matter pathology, was thus also included in our search.The predominant mechanism in the development of axonal injury in TBI is mechanical shearing and stretch forces produced by inertial acceleration/deceleration stresses to the head –28 Figu. This inUnder normal conditions, brain tissue can withstand stretches and easily return to its original geometry without any resulting injury. In contrast, when the strain is rapidly applied, the brain tissue loses its plasticity and acts stiffer, becoming more vulnerable and brittle . In partPrimary axotomy in humans is rare with secondary (delayed) axotomy being the most likely mechanism leading to axonal disconnection , 34, 35.From a clinical point of view, initial loss of consciousness and coma as well as later features such as prolonged vegetative state or cognitive impairment can be characteristics of both focal TBI and DAI, although may be more frequently observed in the latter , 39. TheBy definition, axonal injury is difficult to diagnose using only clinical signs and symptoms. Some clinical features of axonal injury are presumably to a large extent related to the anatomic distribution of DAI. Based on the limited ability of computed tomography (CT) and standard T1- and T2-weighted magnetic resonance imaging (MRI) sequences to precisely detect the underlying axonal injury in TBI, it has been difficult to confirm and diagnose DAI with certainty . HoweverIn addition, advanced neuroimaging has recently enabled improved visualization of surrogate markers for the histopathological features of DAI, and for subsequent surveillance of secondary injury processes. Injury to white matter tracts interconnecting cortical regions, disrupting large scale brain networks of particular importance for complex cognitive functions , 50, areIntracranial pressure monitoring remains a cornerstone in the management of severe TBI patients, although the incidence of raised ICP in DAI is not well established. Maximum ICP has been correlated to the number of identifiable white matter lesions on MRI , and a rThus, the use of ICP monitoring in DAI is controversial . AlthougIn summary, studies evaluating the incidence of elevated ICP in DAI patients are scarce and provide contradictory results. Repeated clinical examinations and neuroimaging may be possible alternatives for monitoring of DAI patients when the initial CT scan is free from or shows only minimal abnormalities, since these patients may have a low risk of intracranial hypertension . NeverthPerfusion CT or xenon-enhanced CT (Xe-CT) are both rapid and widely available techniques for the evaluation of CBF. For Xe-CT, a mobile CT scanner enabling bedside measurement of CBF is used . Althoug2) and brain tissue oxygenation (PBto2). Sjvo2 can be measured using a fiberoptic probe placed in the jugular bulb and ranges between 55–75% under normal conditions. Low Sjvo2 values may suggest hypoperfusion and ischemia and episodes of desaturation correlate with poor outcome  has been proven useful for the monitoring of seizure activity and the depth of sedation especially in those on barbiturate coma , 78. TheThere is limited data on the use of EEG/cEEG in the monitoring of DAI. In a study of 90 patients after diffuse TBI, where EEG recording was applied in the early post-injury phase, the EEG patterns correlated with prognosis . SpecifiTo date, the role of EEG in the monitoring of DAI has not been established. Although there is evidence to support that cEEG monitoring may be useful for the diagnosis of NCS in severe TBI, there is insufficient data in DAI at present. This monitoring modality has also not been shown to improve outcome and/or alter treatment in DAI patients. To date, it should primarily be regarded as a scientific tool awaiting additional studies evaluating its clinical role in the multimodality monitoring of DAI.In recent years, advances in neuroimaging have facilitated DAI diagnostics as well as allowed for more accurate prognosis and monitoring of ongoing, secondary axonal injury. While image acquisition speed, accessibility and accuracy in detecting traumatic intracranial hemorrhages make CT the leading neuroimaging modality in the acute evaluation of TBI patients, its utility in DAI is limited. Although traumatic edema of the brain and petechial hemorrhages in the white matter indicate DAI, CT is generally insensitive for subtle axonal lesions. Hemorrhagic lesions in deep-seated predilection sites for DAI such as the corpus callosum and the rostral brain stem are rarely seen on CT. In addition, non-hemorrhagic lesions, which have been linked to poor outcome , 85, areMagnetic resonance imaging is a more sensitive modality for visualization of DAI-associated lesions and can detect microscopic amounts of blood, as well as non-hemorrhagic lesions secondary to axonal strain Figure . In addiMagnetic resonance imaging sequences sensitive to hemorrhagic lesions include T2*-weighted gradient echo (T2*GRE) and susceptibility-weighted imaging (SWI). Both sequences can detect microhemorrhages, taking advantage of the paramagnetic properties of hemoglobin degradation products. The lesions are typically seen as small hypointense foci in DAI predilection sites and appear larger than their true size due to the magnetic field distortion. Hemorrhagic lesions seem to be fairly stable over time although some reduction of lesion numbers may be seen in the chronic phase following DAI , 87. AddThe Fluid-Attenuated Inversion Recovery (FLAIR) sequence facilitates detection of non-hemorrhagic lesions adjacent to cerebrospinal fluid (CSF) spaces. This sequence is useful for visualizing axonal injuries in periventricular white matter, the corpus callosum and the brain stem , 85. HowThe diffusion-weighted imaging (DWI) sequence is sensitive to the microscopic motion of water molecules , allowinMRI can be difficult to obtain, particularly in the critically ill, since patients’ transfer to the MRI facility may be prevented by clinical instability from intracranial and/or systemic causes. In situations where the time for MRI must for clinical reasons be extended beyond the acute phase, hemorrhagic lesions depicted in particular on SWI sequence seem to have higher prognostic value than other MR sequences. It is notable that conventional MRI sequences may still be insensitive to microstructural damage to axons and injury to white matter tracts of clinical significance can still be missed with this imaging modality .By using image acquisition in multiple directions, the anisotropic diffusion of water molecules can be used to create DTI, providing anatomical reconstruction images of white matter tracts and quantitative measurements of axonal injury . DTI is In summary, DTI is a robust tool to visualize posttraumatic white matter abnormalities. However, variations in data acquisition, analysis techniques, spatial location of investigated structures, lack of correlation with clinical findings, and costs  still imN-acetyl aspartate (NAA), a marker for neuronal and axonal integrity found in high concentrations in neurons  and [99mTc] Ethylcisteinate dimer are the most widely used agents for evaluating regional cerebral blood flow (rCBF) and indirectly, regional cerebral metabolism (Single-photon emission computed tomography (SPECT) uses radiopharmaceutical agents to produce images of physiologic or pathological processes. For TBI, , carbon-11 [11C], and oxygen-15 [15O]. The [18F]-labeled fluorodeoxyglucose (FDG) PET is widely used in brain imaging to measure local glucose metabolism, and thus regional neuronal activity. Similarly, FDG PET studies of DAI patients have revealed regional hypometabolism in medial frontal lobe structures including the cingulate gyrus  , 155 andNeurofilaments (NF) are important components of the axonal cytoskeleton, mainly involved in synapses and neurotransmission . They reNeurofilament light fragments can also be identified in both blood and CSF in TBI , 162. FoIncreased serum and CSF NF-L levels in TBI patients did also correlate with clinical outcome although without any predictive value for DAI . In anotRepeated biomarker sampling during the course of the disease as well as the correlation with advanced neuroimaging is expected to better discern the role of neurofilaments in DAI, their contribution in the pathophysiology of DAI and their prognostic value on outcome.Tau is a structural protein with six isoforms in humans and is a normal constituent of axons. Four distinct isoforms of tau are usually applied in biomarker studies; total-tau (t-tau), cleaved microtubule-associated tau (c-tau), phosphorylated tau (p-tau), and the recently discovered tau-A , 170–172In patients with DAI, t-tau and p-tau levels also increase rapidly within hours after injury, especially in CSF , 174. InThe Simoa platform has shown excellent analytical sensitivity for tau in serum , 175. SeIn DAI, CSF c-tau correlated negatively with the degree of clinical improvement , 180. FuThe association of elevated tau levels with axonal damage is well established. Especially in severe DAI, high tau levels are associated with worse outcome. Ongoing and future research efforts need to focus more on its possible correlation with the extent of injury, interaction with other blood and CSF biomarkers, long-term sequelae, and clinical outcome.Spectrin is a cytoskeletal protein playing an important role in the cytoskeletal structure and maintenance of plasma membrane . In DAI,In rodents, SBDP are detected within minutes after DAI –188. In In severe TBI patients, elevated levels of calpain-mediated 150- and 145-kDa SBDP in CSF were found 24–72 h post-injury , 194 whiSpectrin breakdown products are relatively new biomarkers detected in serum and CSF. Therefore, ample evidence on their significance in the clinical setting is lacking. However, available data suggests that they represent promising molecules in determining the extent of axonal injury and its association to outcome.Axonal injury in TBI has been characterized by amyloid precursor protein (APP) immunohistochemistry, accumulating at sites of axonal transport failure , 196. ThBy cleaving APP, the Aβ peptides Aβ40 and Aβ42, the substrates for Aβ aggregates/plaques also observed in Alzheimer’s disease, are produced . APP andAn increased interest in soluble intermediary Aβ oligomers/protofibrils as the pathogenic form of Aβ has emerged since they are likely to contribute to the development of Alzheimer’s disease , 212. AβThe association between TBI and the development of neurodegenerative diseases, in particular Alzheimer’s disease, has been repeatedly demonstrated , 214. LoCerebral MD is a neurocritical care monitoring technique predominantly used in patients with severe TBI and subarachnoid hemorrhage Table . Its maiUsing MD on 8 severe TBI patients, particularly high ISF Aβ42 values were found in the three DAI patients . In anotn = 5) had lower levels compared to those with DAI (n = 3). Conversely, in a previous MD study, higher tau values were observed pericontusionally in focal TBI patients when compared to tau levels obtained from DAI patients with the MD catheter placed in structurally normal frontal cortex. Early tau levels were inversely correlated with the initial Aβ levels (Tau was also evaluated by MD in eight severe TBI patients . Althougβ levels , 218. Inβ levels .The cytokine response was evaluated by MD in patients with severe DAI suggesting that cytokine production is highly compartmentalized with significant differences between brain parenchymal and systemic concentrations –222. SevFollowing DAI, markers analyzed in MD samples indicating acute and chronic neuroinflammation may potentially be used to guide treatment, as measures for pharmacological response, and/or for tissue outcome. Specifically, MD may aid in detecting factors related to the progression of the disease and in the understanding of the pathophysiology of axonal injury. Therefore, it is likely that data from MD, in combination with widely used measures such as ICP-CPP guided monitoring and protocols, will contribute to the understanding of the pathophysiology of DAI and potentially aid in evaluating novel pharmacological treatments.However, MD is time consuming, usually used for low-molecular weight molecules and frequently characterized by high variability and lack of standardization. In addition, MD remains a predominantly focal measurement technique. To date, there is insufficient data arguing for MD to be used as a clinical decision tool for DAI patients and should rather be considered an integral part of the multimodality monitoring during neurocritical care as well as a research tool.There are numerous additional biomarkers associated to CNS injury that can potentially be related to axonal injury. Examples of such biomarkers are Glial Fibrillary Acidic Protein, ubiquitin carboxy-terminal hydrolase L1 myelin basic protein, microtubule-associated protein 2, protein S-100B and neuron-specific enolase, among others , 223–228Since the above mentioned biomarkers are not specific for axonal injury, at present, their elevations in CSF or serum should be interpreted with caution from both the diagnostic and predictive perspective with regards to DAI.Although considerable progress has been made in the recent years in research, the quest for TBI-specific biomarkers continues. The currently used biomarkers commonly have different specificity- and/or sensitivity, limited availability for bedside analysis and use in daily practice as well as variable half-lives. Moreover, some can also be released from other organ systems during different disease or injury processes.Biomarkers obtained from CSF and ISF are theoretically considered better and more reliable sources compared to blood biomarkers. Therefore, it is preferable to obtain samples from these compartments whenever possible. However, in particular in mild and moderate TBI, there is generally no clinical indication for CSF and, for obvious reasons, ISF sampling by invasive means. On the other hand, blood samples are easily accessible in almost every TBI patient.Nevertheless, important issues relevant to TBI-related blood biomarkers include their relatively low concentrations, proteolytic degradation, the requirement of carrier proteins and the different permeability across the blood–brain barrier for certain biomarkers .Standardization and validation of biomarker levels are other important issues since different methods of analysis, preparation and sample quality can provide different results among laboratories and centers which can cause problems during the interpretation and comparison of results . As the ICP and CPP monitoring as well as ICP-CPP guided therapy are advised in all severe TBI patients with suspected axonal injury and decreased level of consciousness especially in the initial post-injury phase.Conventional MRI scan sequences such as FLAIR, DWI, and SWI should be considered in the first post-injury period following TBI to detect and confirm the presence of DAI.Advanced MRI techniques such as DTI and MRS are useful modalities for further delineation of axonal damage in TBI, particularly in the subacute and chronic phase.Due to high cost and limited availability, PET scanning is recommended solely as a valuable research tool although not to date in clinical management.Biomarkers specific for axonal injury can be analyzed in blood and CSF from the acute to chronic post-injury period in TBI, aiming to aid in the understanding of the axonal injury process, follow the course of the disease, monitor for possible deterioration, estimate the extent of axonal injury and aid in prognostication.Repeated clinical examinations and neuropsychological tests can provide invaluable information on the extent of injury, prognosis and for monitoring possible recovery or exacerbation of cognitive functions and mental status.Although axonal injury has traditionally been associated with an impaired level of consciousness and poor prognosis, patients with confirmed axonal damage can achieve a good clinical outcome. Using advanced neuroimaging, axonal injury is increasingly recognized also in mild TBI or sports-related concussions. Many tenets of the pathophysiology of axonal injury are being elucidated through major efforts in basic science and medical research. Nonetheless, it remains an exceedingly complex subtype of TBI with many unknown secondary pathological processes. Since the secondary injury cascades are continuing for a considerable time post-injury, monitoring is critically important for clinical as well as research purposes. Advanced imaging techniques such as MRS, DTI and PET show promise in better identifying and quantifying axonal injury and its importance for patient outcome. In addition, both invasive and non-invasive neurocritical care techniques are becoming increasingly important in monitoring axonal injury. Numerous biomarkers with, plausibly, high specificity for axonal damage have been and are being developed. This evolving field of TBI research is promising for the development of bedside, rapid analysis kits for small-volume body fluids. When these novel biomarkers are available for routine use as monitoring tools for axonal injury, they may in the future aid in the detection and prevention of secondary axotomy and atrophy of white matter tracts. They may also be used as secondary outcome measures in DAI, assist in the development of novel therapies, guide treatment, and monitor treatment response. Finally, the short-and long-term monitoring options for axonal pathology and its progression described in this review may become crucial for the prevention of neurodegeneration at the chronic stage in DAI.Study concept and design, drafting of the manuscript, analysis and interpretation of data, and critical revision of the manuscript: PT, SAH, and NM. Acquisition of data: PT and SAH. Study supervision: NM.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.


Optimally treated heart failure (HF) patients often have persisting symptoms and poor health-related quality of life. Comorbidities are common, but little is known about their impact on these factors, and guideline-driven HF care remains focused on cardiovascular status. The following hypotheses were tested: (i) comorbidities are associated with more severe symptoms and functional limitations and subsequently worse patient-rated health in HF, and (ii) these patterns of association differ among selected comorbidities.The Swedish Heart Failure Registry (SHFR) is a national population-based register of HF patients admitted to >85% of hospitals in Sweden or attending outpatient clinics. This study included 10,575 HF patients with patient-rated health recorded during first registration in the SHFR (1 February 2008 to 1 November 2013). An a priori health model and sequences-of-regressions analysis were used to test associations among comorbidities and patient-reported symptoms, functional limitations, and patient-rated health. Patient-rated health measures included the EuroQol–5 dimension (EQ-5D) questionnaire and the EuroQol visual analogue scale (EQ-VAS). EQ-VAS score ranges from 0  to 100 . Patient-rated health declined progressively from patients with no comorbidities  to patients with cardiovascular comorbidities  to patients with non-cardiovascular comorbidities . The relationships among cardiovascular comorbidities and patient-rated health were explained by their associations with anxiety or depression  and with pain . Associations of non-cardiovascular comorbidities with patient-rated health were explained by their associations with shortness of breath  and with fatigue . There were direct associations between all symptoms and patient-rated health, and indirect associations via functional limitations. Anxiety or depression had the strongest association with functional limitations  and patient-rated health . HF optimizing therapies did not influence these associations. Key limitations of the study include the cross-sectional design and unclear generalisability to other populations. Further prospective HF studies are required to test the consistency of the relationships and their implications for health.Identification of distinct comorbidity health pathways in HF could provide the evidence for individualised person-centred care that targets specific comorbidities and associated symptoms. Using cross-sectional data from the Swedish Heart Failure Registry, Claire Lawson and colleagues examine the comorbidity patient-rated health pathways in heart failure patients Heart failure is an increasingly common condition, and patients often experience persistent symptoms and poor quality of life, even when they are receiving the best possible treatment for their heart failure.Most heart failure patients have other conditions that dominate their health experience, yet heart failure treatment focuses on their cardiovascular status.There is a lack of understanding about the relationships among different comorbidities and quality of life in heart failure, which are important to guide individualised treatment plans for patients.We used an established health-related quality of life model to develop and test a new heart failure health model that included the most common heart failure comorbidities.We tested this model by examining the postulated relationships among comorbidities, symptoms and functional limitations reported by patients, and their overall health experience, using a national register of heart failure patients in Sweden.We found that non-cardiovascular comorbidities were associated with much higher overall symptom burden and more severe symptoms than cardiovascular comorbidities.Predominant symptoms for cardiovascular comorbidities were pain and anxiety, whereas for non-cardiovascular comorbidities they were shortness of breath and fatigue.Heart failure optimising therapies did not influence these symptoms, functional limitations, or quality of life.Current guidelines in heart failure focus on improving cardiovascular status in response to common heart failure symptoms .Our study shows that for some patients, these symptoms might be driven by non-cardiovascular conditions such as diabetes and renal disease, rather than their cardiovascular status. We found that cardiovascular comorbidities were more likely to be associated with pain and anxiety than shortness of breath or fatigue.To improve health-related quality of life, heart failure guideline-driven care needs to include optimal management of the most prevalent non-cardiovascular comorbidities and routine management of pain and anxiety or depression.To provide individualised patient care, guidelines need to better align symptoms with the cardiovascular and non-cardiovascular status of the patient. Heart failure (HF) is a complex clinical syndrome of multiple symptoms, functional impairments, and poor health-related quality of life (HRQoL). With modern therapies, HF patients are now living longer but with a potentially higher symptom burden  that canHF patients are usually older, with a high number of comorbidities, and a third of patients report that other medical conditions dominate their health experience , yet guiThe SHFR is a national population-based register of all HF patients admitted to hospitals or attending outpatient clinics in participating primary care units . The regEstablishment of the registry and analysis of data were approved by a multisite ethics committee and conform to the Declaration of Helsinki. Individual patient consent is not required, but patients are informed of entry into national registries and can opt out. Access to the SHFR was granted following project approval  by the SPreviously, an a priori model by Wilson and Cleary  hypothesHF patient factors were age, sex, marital status (single or married/partner), body mass index (BMI), smoking status (current or former/none), HF duration (≥6 or <6 months), heart rate, haemoglobin, devices, and prescription of HF optimising drugs  and diuretics. Environmental factors were healthcare provider (inpatient or outpatient) and speciality (cardiology or medicine). Of the continuous variables, age and heart rate values were all within the plausible range, and BMI and haemoglobin were truncated at the boundaries of their respective plausible ranges .2.HF biological status was based on left ventricular ejection fraction defined as reduced (<40%), midrange (40%–49%), or preserved (≥50%). For the sequences of regressions analyses, ejection fraction was dichotomised as ≥40% or <40%. Cardiovascular comorbidities were hypertension, dilated cardiomyopathy (DCM), valve disease, atrial fibrillation (AF), and ischemic heart disease (IHD), and non-cardiovascular comorbidities were diabetes, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD). CKD was defined by an estimated glomerular filtration rate of <60 ml/min/1.73 mPrevious evidence has shown only weak associations between HF biological status and shortness of breath (SOB) –20, but Patient-rated health is a known predictor of mortality in HF . In thisWe dichotomised patient-rated health (EQ-VAS) at the population mean  to describe patient and clinical characteristics in a contingency table. Summary statistics are means and standard deviations for continuous data with symmetrical distribution, whilst skewed continuous data are described by medians with interquartile ranges. Dichotomous data are summarised by frequencies and percent prevalence.We used sequences of regressions , a subclP < 0.01, and analyses were performed using StataMP 13. There were very small proportions of missing values for a few explanatory and intermediate variables , hypertension (52%), and IHD (54%). Non-cardiovascular comorbidities were also frequent: 44% of patients had CKD, 17% had COPD, and 24% had diabetes. There were 415 (3.9%) HF patients without any comorbidities. These patients were on average 10 years younger, mostly outpatients (83%), and much more likely to have shorter duration of HF (<6 months) than HF patients with comorbidities (82% versus 50%). The prevalence of symptoms and functional limitations was higher for HF patients with comorbidities than for those without and differed between those with cardiovascular and non-cardiovascular comorbidities, as shown in There was a marked increase in the prevalence of symptoms and functional limitations from HF patients with no comorbidities to those with cardiovascular comorbidities to those with non-cardiovascular comorbidities. Respectively, mean prevalence among the 3 comorbidity categories was 26%, 37%, and 46% for marked or severe SOB; 27%, 36%, and 44% for marked or severe fatigue; 45%, 52%, and 59% for pain; 42%, 46%, and 48% for anxiety or depression; and 28%, 38%, and 45% for functional limitations. Patient-rated health showed a similar pattern , where mR2 = 0.32, 95% CI 0.31 to 0.34). There were direct negative associations with patient-rated health for older age, single status, longer HF duration, higher heart rate, prescribed diuretic, being an inpatient, having diabetes, and having symptoms and functional limitations. Care under cardiology compared to general medicine was associated with better patient-rated health . Two of the strongest direct associations with worse patient-rated health were anxiety or depression  and functional limitations . Whilst most comorbidities had significant crude associations with patient-rated health  were associated with the highest overall symptom burden and with more severe symptoms than were associated with cardiovascular comorbidities or with no comorbidities. The predominant symptoms associated with COPD, diabetes, and CKD were SOB and fatigue, although COPD was associated with all 4 symptoms. Explanations for the increase in cardiovascular-related symptoms with non-cardiovascular diseases are multiple and varied. It is likely that comorbidities interact with the HF via conflicts in medications, efficacy of interventions, patient self-care, or shared risk factors such as obesity and reduced exercise .The implications of both these findings are important. The symptom focus in HF guidelines and clinical practice is usually on SOB, leg swelling, and fatigue . These sOur findings show that a potential mismatch exists between these guidelines and patient-rated health, with increased SOB and fatigue being driven by non-cardiovascular status and pain and anxiety or depression being driven by cardiovascular status. This indicates that, for HF patients’ health to improve, new interventions for common HF symptoms need to include the most prevalent non-cardiovascular comorbidities and that management of pain and anxiety or depression needs to become part of routine guideline-driven care and would be an important addition to clinically relevant end-points in clinical trials.Our third key finding was that although HF optimising therapies were prescribed for most SHFR patients, with minor exception, these therapies were not associated directly or indirectly with comorbidities, symptoms, functional limitations, or patient-rated health. Previous evidence has found only modest benefit from HF pharmacological treatment for quality of life in HF , but we The SHFR includes patients from most (>85%) hospitals in Sweden as well as primary care units and covers the full range of patients with preserved and reduced ejection fraction as well as those with comorbidities, who are often excluded from clinical trials. The availability of such data meant that an a priori HF health model could be hypothesized and tested to provide a detailed concept of the potential pathways between comorbidities and patient-rated health in HF. It is important to note that health measures were only available for a quarter of all patients entered into the register. Whilst the SHFR was created in 2005, EQ-5D has only been included as part of baseline registrations since February 2008. There has been a slow increase since then in the proportion of records completed, particularly in the inpatient setting. Consequently, our sample was predominantly based in the outpatient setting, and patients were slightly younger, more often men, more often married, with a reduced ejected fraction, and more frequently prescribed HF optimising medications. This could imply an underestimation of poor patient-rated health in our study, as older age groups, women, and patients in hospital reported more symptoms than their younger, male, and outpatient counterparts. The impact of such differences on the complex relationships between comorbidities and health is difficult to estimate; we took account of these factors in the model, but we cannot rule out unmeasured confounding.Whilst patient-rated health in our study was based on EQ-VAS, which is a simple, valid, and reliable measure of patient’s own health, comorbidities and symptoms were based on clinical recording, which can be subject to misclassification, leading to under-ascertainment. That said, any such misclassification is likely to bias the associations towards the null value. We used sequences of regressions for our analyses, meaning that direct and indirect associations between variables could be exposed that are often hidden by conventional statistical analyses. However, as with any method of analysis, the validity of any model depends on having considered the most influential explanatory variables at the outset. The study was retrospective and observational, with few missing data, but an important limitation was the lack of some relevant variables that might impact health such as social status/deprivation, emotional, and spiritual measures. However, our intention was to uncover the indirect relations between comorbidities and patient-rated health through subjective patient-reported health measures as opposed to producing a definitive HRQoL model, and we did use a range of clinical, patient, environmental, and biological variables based on an a priori hypothesized model. Although the investigation used a cross-sectional design, it provides novel and original findings for a HF health model that can be further tested in prospective studies and externally validated in different countries to assess the consistency of relationships postulated by the model.In HF, distinct health pathways exist among cardiovascular and non-cardiovascular comorbidities that are not influenced by HF optimising therapies. Our HF health model reveals the potential interplay of different factors that underpin health in HF. These findings highlight the need to refocus on person-centred HF care and consider the specific mechanisms that contribute to overall patient health, and to design effective interventions that target the comorbidities and the range of symptoms with the biggest impact on health.S1 Checklist(DOCX)Click here for additional data file.S1 Methods(DOCX)Click here for additional data file.S1 Proposal(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


Cancer cells reprogram their metabolism to maintain viability via genetic mutations and epigenetic alterations, expressing overall dynamic heterogeneity. The complex relaxation mechanisms of nuclear spins provide unique and convertible tissue contrasts, making magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) pertinent imaging tools in both clinics and research. In this review, we summarized MR methods that visualize tumor characteristics and its metabolic phenotypes on an anatomical, microvascular, microstructural, microenvironmental, and metabolomics scale. The review will progress from the utilities of basic spin-relaxation contrasts in cancer imaging to more advanced imaging methods that measure tumor-distinctive parameters such as perfusion, water diffusion, magnetic susceptibility, oxygenation, acidosis, redox state, and cell death. Analytical methods to assess tumor heterogeneity are also reviewed in brief. Although the clinical utility of tumor heterogeneity from imaging is debatable, the quantification of tumor heterogeneity using functional and metabolic MR images with development of robust analytical methods and improved MR methods may offer more critical roles of tumor heterogeneity data in clinics. MRI/MRS can also provide insightful information on pharmacometabolomics, biomarker discovery, disease diagnosis and prognosis, and treatment response. With these future directions in mind, we anticipate the widespread utilization of these MR-based techniques in studying Cancer cells by definition are highly proliferative and grow rapidly. Tumors adapt their metabolism to maintain viability, which is one of the emerging hallmarks of cancer . The comKnowledge of metabolic patterns in cancer can be implemented not only for early detection and diagnosis of cancer but also in the evaluation of tumor response to medical interventions and therapies . Many taIdeal utilization of molecular imaging is to “dose paint” the radiotherapy dose administered to each tumor with reference to positron emission tomography (PET)  and to iComplex cancer metabolism and associated characteristics have been extensively explored by magnetic resonance imaging (MRI) and spectroscopy (MRS) using the versatile relaxation mechanisms of nuclear spins that provide unique and convertible tissue contrasts. Advances in MR techniques have enabled noninvasive access to significant amounts of useful information on cancer metabolism and tumor heterogeneity ranging in spatial scales from gross anatomy, biophysical characteristics, and functional or metabolic imaging . It is iT1 and T2. Longitudinal relaxation (T1) relies on a dipole-dipole interaction of adjacent spins, specifying how fast the longitudinal magnetization is recovered. Transverse relaxation (T2) refers to the decay rate of transverse magnetization due to the progressive dephasing of excited spins ..b-valuesT2∗-weighted MR acquisitions with various subject orientations along the B0 magnetic field are required for the directional information, having STI impractical for clinical use.Diffusion tensor imaging (DTI) assesses changes in microstructural anisotropy from water diffusion by applying several directional diffusion gradients. Measuring fractional anisotropy (FA) from DTI can detect blockage of the ducts and lobules by cancer cells in the breast, which increases the extracellular tortuosity and restriction of the water movement, causing a reduction of the diffusion coefficients in all directions and consequently also decreasing the diffusion anisotropy . DTI als in vivo by introducing shear waves and imaging their propagation using MRI pyruvate has demonstrated increased lactate labeling in tumors [kpyr-lac [13C]pyruvate in a preclinical glioma model as the labeled carbon is retained in acetyl-CoA and enters the TCA cycle [13C]glutamate production in tumors implies that the metabolic pathway from pyruvate to the TCA cycle is suppressed in the tumor as compared to the contralateral normal-appearing brain tissue, while glycolytic characteristics of tumors could be still assessed by increased [2-13C]lactate. Using hyperpolarized [2-13C]pyruvate, it was further demonstrated that dysregulated mitochondrial metabolism  is potentially recoverable in glioma by inhibiting pyruvate dehydrogenase kinase (PDK) with dichloroacetate (DCA) . TCA cycle . In partte (DCA) . The utibstrates –134.1H) magnetic resonance spectroscopic imaging (MRSI) has been a powerful tool for characterizing tumor metabolism by quantifying cancer-related metabolites such as choline, creatine, N-acetyl aspartate (NAA), and 2-hydroxyglutarate (2HG). Increased levels of choline, specifically, are associated with tumor proliferation, with recent studies emphasizing the complex interactions between choline metabolism and oncogenic signaling pyruvate studies and illuminated a clear translational path for other additional applications [T1 decays and lower polarizations), and biological validation in animals.Most functional and metabolic MR methods, however, are rarely used in clinics due to low signal sensitivities, resulting in poor spatial resolution and reproducibility.  in vivo , 185. CE in vivo , 187 andications , 188. DNications . Other hThe interaction between tumor metabolism and cancer biology is essential for supporting tumor growth and prolonging survival during stress  and has k-space sampling schemes and parallel imaging methods can lead to accelerated data acquisition with a narrower point spread function, achieving higher spatial resolution and improved imaging contrast. This would be beneficial for analyzing tumor heterogeneity, particularly in the setting of dynamic imaging or metabolic imaging. More robust assessments of tissue heterogeneity should be available by enhancing image integrity at high-resolutions via improvements in MR hardware . It is also critical to understand each data acquisition and reconstruction scheme for proper image analysis and valid assessment of associated metabolic parameters. For example, some imaging signals from neighboring voxels are not necessarily entirely independent, as seen in advanced MRI techniques where zero-filling techniques are employed to keep scan times as fast as allowable [Although spatial and metabolic heterogeneity of tumor is an important prognostic factor, the current clinical utility of quantifying tumor heterogeneity from imaging is controversial , 191 andllowable , and thillowable , 193. in vivo imaging techniques such as the integration of MR and PET  would further help in unraveling the molecular complexities of cancer metabolism. The authors believe the development of integrated bioinformatics tools would aid in the handling of spatial, temporal, and multiparametric data from cancer metabolic imaging. With these future directions in mind, we anticipate the widespread integration of these MR-based approaches into the study of cancer biology in vivo to better address significant clinical needs. Prospective trials with well-defined endpoints are encouraged to evaluate the benefits of these emerging imaging tools in the management of malignancies.Studies based on a single modality might oversimplify the dynamics of cancer metabolism into a static description. A combination of multi-modal


Immediate early genes (IEGs) were traditionally used as markers of neuronal activity in striatum in response to stimuli including drugs of abuse such as psychostimulants. Early studies using these neuronal activity markers led to important insights in striatal neuron subtype responsiveness to psychostimulants. Such studies have helped identify striatum as a critical brain center for motivational, reinforcement and habitual behaviors in psychostimulant addiction. While the use of IEGs as neuronal activity markers in response to psychostimulants and other stimuli persists today, the functional role and implications of these IEGs has often been neglected. Nonetheless, there is a subset of research that investigates the functional role of IEGs in molecular, cellular and behavioral alterations by psychostimulants through striatal medium spiny neuron (MSN) subtypes, the two projection neuron subtypes in striatum. This review article will address and highlight the studies that provide a functional mechanism by which IEGs mediate psychostimulant molecular, cellular and behavioral plasticity through MSN subtypes. Insight into the functional role of IEGs in striatal MSN subtypes could provide improved understanding into addiction and neuropsychiatric diseases affecting striatum, such as affective disorders and compulsive disorders characterized by dysfunctional motivation and habitual behavior. Immediate early genes (IEGs) are activated transiently and rapidly throughout the brain by many cellular stimuli including psychostimulants. Traditionally, IEGs are used as markers of neuronal activity, in striatum and other brain regions, in response to psychostimulants. The striatum consists of the dorsal striatum, which regulates actions and habits vs. ventral striatum (a.k.a.- nucleus accumbens- NAc), which is involved in motivation and reinforcement -∆FosB line crossed to a NSE-tetracycline transactivator (ttA) line resulted in expression of ∆FosB in striatal D1-MSNs  induction in striatum with acute psychostimulants is D1 receptor dependent (Daunais and McGinty, While studies examining psychostimulant-mediated IEG function in D1-MSN vs. D2-MSN subtypes are sparse, they have provided some insight into mechanisms by which IEGs act in these neuron subtypes. This includes actions primarily through D1-MSNs in psychostimulant-mediated molecular, cellular and behavioral plasticity. Overall we focus on three select IEGs that have been examined in MSN subtypes in psychostimulant action. However, examination of other psychostimulant relevant IEGs, such as Arc and CREB (Carlezon et al., MKL and RC both contributed to the writing of the manuscript, as well as the preparations of the figure and table.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.


Eukaryotic cells are characterized by a considerable increase in subcellular compartmentalization when compared to prokaryotes. Most evidence suggests that the earliest eukaryotes consisted of mitochondria derived from an α-proteobacterial ancestor enclosed within an archaeal host cell. However, what benefits the archaeal host and the proto-mitochondrial endosymbiont might have obtained at the beginning of this endosymbiotic relationship remains unclear. In this work, I argue that heat generated by the proto-mitochondrion initially permitted an archaeon living at high temperatures to colonize a cooler environment, thereby removing apparent limitations on cellular complexity. Furthermore, heat generation by the endosymbiont would have provided phenotypic flexibility not available through fixed alleles selected for fitness at specific temperatures. Finally, a role for heat production by the proto-mitochondrion bridges a conceptual gap between initial endosymbiont entry to the archaeal host and a later role for mitochondrial ATP production in permitting increased cellular complexity. Available evidence suggests that two prokaryotes, an archaeon and a bacterium, collaborated Margulis  in the eMitochondria are eukaryotic organelles derived from α-proteobacterial endosymbionts capable of generating ATP by oxidative phosphorylation Gray . The earHere, I propose that the initial driving force allowing maintenance of the proto-mitochondrial endosymbiont within its archaeal host was production of heat, thereby permitting endurance of lower temperatures. Only afterward did ATP generation by the early mitochondrion contribute to the increased apparent complexity exhibited by eukaryotes.High temperatures likely hastened the formation of ancestral life by accelerating reactions required for metabolism prior to the evolution of more specific and efficient enzymes  from mesophilic bacteria already residing at lower temperatures  converts electronic energy to a proton gradient used to power mechanochemistry and to drive metabolite movement across membranes West . During In addition, cells can purposely augment thermogenesis by expressing proteins promoting mitochondrial heat production. For example, uncoupling proteins can further increase proton leak, as illustrated by brown fat thermogenesis in mammals (Busiello et al. 2 and CO2 to produce acetyl-CoA and downstream products for consumption and oxidation by the endosymbiont. Alternatively, both host and proto-mitochondrion may have fed upon organic carbon. Lokiarchaeota and other Asgard members have not yet been cultivated, and so the metabolic strategies used by these organisms are not yet fully revealed.I suggest a scenario in which a respiring proto-mitochondrial endosymbiont was encountered and completely enveloped by an archaeal host typically resident at high temperatures. Phylogenomic analyses imply that the archaeal host contributing to the formation of eukaryotes may have emerged from the recently discovered ‘Asgard’ superphylum of archaea (Zaremba-Niedzwiedzka et al. Immediately after entry, the proto-mitochondrion need not have provided any particular advantage to its host, and might have even been a parasite rather than an endosymbiont. However, upon colonization of a novel, cooler environment, the collection of heat-generating structures enclosed within the plasma membrane would allow the host to maintain the cell’s internal temperature at a value higher than ambient Fig. . Heat woAs this proposed partnership allowed movement of host cells and their resident endosymbionts to colder climates, the apparent barriers to genome size and diversity presented by life at high temperatures (Laksanalamai et al. First, after the early eukaryote had initially colonized environments of lower temperature, further genetic changes and acquisitions would have rendered unnecessary a priority on proto-mitochondrial heat generation. Subsequently, better coupling of ETC activity to ATP synthesis, coincident with the introduction of an antiporter exchanging cytosolic ADP for ATP synthesized in the mitochondria, would have allowed greater ATP availability to the early eukaryotic cell Fig. . While dSecond, it has been suggested that single cells are generally in temperature equilibrium with their environment (Johnson et al. Finally, I suggest that proto-mitochondrial heat production provided additional flexibility to the eukaryotic ancestor population that would be difficult to obtain by fixation of mutations and gene transfers. Since one might expect stochastic differences in the quantity of heat-producing endosymbionts among a population of proto-eukaryotic cells, such a population might be resilient in the face of environmental temperature changes. Upon encountering lower temperatures, those cells with more heat-producing endosymbionts would flourish, and conversely, upon meeting higher temperatures, those cells with a more limited endosymbiont load would prosper Fig. , therebyAs highlighted in this work, mitochondria can be a significant source of heat production, and the ability to convert energy from electrons into heat may have been the earliest basis for integration of the proto-mitochondrion with its archaeal host. Such a scenario bridges a conceptual gap between endosymbiont entry and the eventual utility of mitochondrial ATP generation in fostering increased complexity. Strong support for this model would be obtained by discovery of a modern-day intracellular endosymbiont that currently provides heat to its host organism. In addition, phylogenetic analyses comparing genes and proteins from mitochondria, bacterial relatives of mitochondria, and the archaeal kin of eukaryotes, with a focus on temperature-related parameters such as guanine-cytosine content, amino acid usage, and activity of reconstructed ancestral proteins Akanuma , can proBeyond their roles in bioenergetics, mitochondria are the location of other widely conserved cellular processes. For example, iron–sulfur cluster generation is a primary function of mitochondria (Karnkowska et al.