For 20 years, the intricacies in bacteriophage Mu replication and its regulation were elucidated in collaboration between Ariane Toussaint and her co-workers in the Laboratory of Genetics at the Université Libre de Bruxelles, and the groups of Martin Pato and N. Patrick Higgins in the US. Here, to honor Martin Pato’s scientific passion and rigor, we tell the history of this long-term sharing of results, ideas and experiments between the three groups, and Martin’s final discovery of a very unexpected step in the initiation of Mu replication, the joining of Mu DNA ends separated by 38 kB with the assistance of the host DNA gyrase. Acting as an Editor for this Special Issue dedicated to phage research in Belgium did not immediately sound like a cup of tea. Despite being officially retired for too long, we could not resist writing this contribution to honor the memory and scientific achievements of a very special friend and collaborator, Martin Pato, who passed away on 7 May 2022. He regularly visited Ariane’s lab at ULB, between the middle 1970s and 1990s, a time when phages were top research models for both genetics and biochemistry in Belgium and all over the world. The publication of the first complete genomic sequence of a virus, phage MS2, by W. Fiers’s group [In the early 1970s, several research groups around the world started working on a “weird” mutator phage (Mu), discovered by Larry Taylor . The lonAriane and Martin first met in 1974 at an EMBO workshop on restriction enzymes and DNA sequencing. Walter Fiers, Marc van Montagu and Jeff Schell organized this event in a middle-age cloister in Drongen, near Ghent, that was transformed into a Meeting Center. After completing a PhD thesis in Don Glazer’s lab at Berkeley in 1968, Martin worked in the University Institute of Microbiology, in Copenhagen, with K. von Meyenburg and J. Zeuthen. All three were invited to the Drongen meeting. E. coli chromosomal DNA synthesis and followed the direction of fork movement toward termination [lac sex factor [E. coli precisely match the rate of transcription with the rate of protein synthesis [During his PhD, Martin identified the origin of mination ,5. He demination . In Copex factor  and colix factor . Curiousynthesis ,10. ThisE.coli host DNA. These structures accumulated during Mu development [E. coli lac, gal and mal operons and in phage ʎ polar mutants. The same IS sequence could appear at different sites in a chromosome. In the F plasmid, ISs were shown to mark sites where the plasmid integrates into the bacterial chromosome. In R plasmids, ISs marked the limit between the plasmid moiety and a ‘resistance module’. Some ISs contained a promoter that could alter expression of genes adjacent to the IS site of insertion. Transposable antibiotic resistance genes had been shown to move from one replicon to another both in Gram+ and Gram− bacteria and were found on various plasmids. Some of these properties had also been demonstrated for Mu insertions [lac or a ʎ derivative deficient for integration and replication [Martin returned to the US, accepting a position at the National Jewish Hospital (NJH) in Denver, Colorado, near Norman Pace’s group. At the time, Mu biology and biochemistry were shrouded in mystery. Across the street from NJH, at the University Hospital, Barbara Waggoner was finishing her thesis with Larry Taylor. They characterized, via electron microscopy (EM), unexpectedly large covalently closed circular DNA molecules containing a Mu copy bound to elopment . Ariane elopment . In 1976elopment . The intsertions . In partlication ,16. Thes3H-labeled DNA extracted at various times after the induction of a Mu prophage, DNA isolation on a CsCl gradient and EM analysis, Barbara, Martin and Larry established that (1) newly replicated Mu-specific DNA was present 9 min after induction, and two prophage copies were present at 12 min and six by 15 min; (2) covalently closed circular DNA of heterogenous length (Hc-DNA), not correlated with Mu length, appeared 14 min after induction and diminished in length with time until shortly before lysis. Hc-DNA, thus, appeared after at least one round of prophage replication; (3) formation of Hc-DNA required that the prophage was induced and could replicate and, hence, was correlated with Mu replication.One article in the book is of particular interest for this story . By a coIn the same book, with A.I. Bukhari, the ULB group published a model based on the analysis of Mu-mediated chromosomal rearrangements of host DNA, proposing that Mu replication always proceeds from integrated Mu copies and is systematically accompanied by a chromosomal rearrangement , a process that generates Hc-DNA . This maA and B genes and both termini, replicated upon induction. Deletion of part of gene B impaired replication, which was only partially restored when protein B was provided in trans, whereas supplying gene B and additional functional DNA between genes B and C allowed for extensive replication of the mini-Mu DNA. Functions, thus, existed between genes B and C, which amplify the replication of Mu DNA [arm” gene product [Mu ends and pA and pB, the transposase and transposition activator, respectively, are essential for phage DNA replication. To identify other genes or sites essential for replication, the ULB group isolated internal Mu deletions of various lengths, generating so- called mini-Mus. This also facilitated EM analysis of the Mu moiety in Hc-DNA. Mini-Mu replication was tested in Denver by labeling and DNA–DNA hybridization, while EM analysis of DNA accumulating during replication was visualized using EM at ULB. Mini-Mus, deleted of most of the internal region of the phage DNA, but still containing at least the repressor and replication f Mu DNA , later s product .In 1979, Jim Shapiro published a model for the mechanism of replicative transposition . The modIn 1983, Pat Higgins, then at the University of Wyoming in Laramie, joined the collaboration. He was developing an in vitro replication system for Mu, a good addition to the genetic and biochemical approaches . From th9 with IS1 [10 with IS10 [Kn7701, had the Tn located at a position that should not have blocked replication. Nonetheless, that phage grew very poorly with a long delay in the onset of replication after induction. To further check on this length dependence, Martin suggested isolating “Maxi-Mu’s”. This was readily carried out by Michel Faelen at ULB [While we progressed in understanding Mu replication, research on the mechanisms of transposition of IS and Tn elements was going on. In complex transposons containing two IS sequences flanking the antibiotic resistance module , the frn at ULB . The resIn 1983, Martin and his technician, Claudia Reich, discovered that Mu transposase was unstable  and demoIn 1985, the Mizuuchi lab published a seminal paper describing a soluble system that would carry out efficient Mu transposition reactions in vitro . They idVirology by Martha Howe’s lab [nuA and nuB. Both nu mutants could form plaques on lawns of mutant E. coli strains that wild-type (WT) Mu would not grow on. The manuscript stated that the E. coli mutation was in himA or himB genes, which encode the IHF protein that was essential for Mu induction. The rare nu mutations appeared at a frequency estimated between 10−6 and 10−9 per lysogen and both mutations mapped near the Mu genes G and I, which are near the center of the viral DNA. At the conference, Jeff Miller told Pat that the E. coli mutation was actually in gyrB rather than in IHF, and it had a temperature-sensitive phenotype at 42 °C. Pat called Martin to discuss one simple hypothesis: the Mu virus could compensate for a weak gyrase by strengthening a gyrase binding site at its center. From Pat’s background of work on gyrase in the Cozzarelli lab [nuA and nuB strains from Martha Howe and she sent both mutants to both labs immediately. Pat purified DNAs from Mu and both nu mutants and carried out quinolone-induced gyrase cleavage reactions. A single strong cleavage site appeared on one restriction fragment for all three DNAs. Dramatically, the cleavage efficiency was nuB > nuA > WT. After seeing the results on a poor fax, Martin flew to Pat’s lab in Birmingham to plan the immediate work, obtain stocks of purified gyrase subunits and special reagents for supercoiling DNA cleavage analyses. The name SGS for "strong gyrase site" was chosen for the site. Returning to Denver with ample socks of critical reagents and gyrase, Martin cloned all three SGS sites into M13 vectors for sequencing and into pBR332 for supercoiling analysis, quinolone cleavage assays and for other purposes yet to be determined. The three sites were named SGS WT, SGSnuB1 and SGSnuB103. Sequencing of cleaved DNA was carried out with the chain termination method and results showed a band in all four sequencing lanes that marked gyrase cleavage sites. Chain-terminating polymerases sometimes add an untemplated nucleotide at the sequence end, providing slightly ambiguous data. With his usual tenacity, Martin wanted to recheck, and he ligated linkers directly onto both ends of the cleaved DNAs and cloned them for sequencing to prove the expected 4 bp-break overhang in each site. Finally, he constructed a Mu prophage variant with a deletion of the SGS. Replication of the deletion mutant was delayed by about 100 min relative to Mu WT. The manuscript was published in PNAS [At a 1989 Gordon conference, Pat learned an interesting fact about a paper published 7 years earlier in we’s lab . Martha elli lab ,33, he a in PNAS . The gyrIn 2004, Martin published a study that proved the center of Mu DNA to be the optimal position for the SGS . As usuaIn 1995, a final collaborative paper on the Mu gyrase SGS mechanism was published, reporting on the analysis of the biochemical reaction steps that progressed or were delayed after induction of Mu lysogens that lack the SGS. Transcription and protein production occurred normally. Strikingly, the step of strand cleavage at Mu ends and strand transfer to a new location was delayed by 40 min without the SGS. The critical step promoted by gyrase at SGS was, thus, the assembly of a functional transpososome . This obE. coli O157:H7 Sakai genome. Martin’s last paper was published in the Journal of Bacteriology in 2006 [Martin remained curious about whether any ”strong” gyrase cleavage sites that had been studied by many prior labs could function at the center of Mu. He made multiple attempts to find alternatives from 1999 to 2003 ,39,40,41 in 2006 . He diss in 2006 .In retrospect, it is curious that all the labs studying single-molecule DNA–Gyrase complexes chose Martin’s pBR322-derived plasmid with the strongest Mu SGSnuB103 sequence to bind gyrase for analysis of discrete steps in a gyrase reaction mechanism. This was used to measure catalytic rates in vitro ,45. It mE. coli and Salmonella Typhimurium have nearly identical GyrA and GyrB proteins and identical promoter sequences for essential genes. Nonetheless, Salmonella maintains an average chromosome supercoil density 15% lower than E. coli, and E coli cannot grow at the supercoil density maintained in Salmonella [Salmonella and E. coli GyrA, respectively [The work from Martin’s lab provided a significant clue to supercoil research in bacteria. Most well-studied bacteria have negatively supercoiled chromosomes and contain easily recognized genes coding for GyrA and GyrB. Because supercoiling can be influenced both by mutations in gyrase subunits and mutations in high-affinity gyrase binding sites, bacterial species have the potential to optimize the supercoil levels in different niches. lmonella . The solectively ,48.Martin was incredibly cautious and precise in his science, always testing or proving things via complementary approaches. But he also showed an enchanting and unique personality. When he visited Pat’s lab in 1989 to work on the SGS project, they took off on Sunday to stretch their legs on a 5-mile loop hike near the Appalachian Trail. It is an old Indian trail that starts near Birmingham and goes all the way to upper Canada. Near the end of their mini trek, Pat’s 8-year-old daughter, Rachel, “sprained” her ankle and convinced Martin to hoist her up on his shoulder on the way home, which he did with ease. She still remembers that day. He loved traveling. He had the amazing ambition to see all of Vermeer’s paintings and followed them wherever they happened to be displayed. He visited Afghanistan in the 1970s, and it was wonderful to listen to his memories while we traveled around Pakistan, during a memorable Mu workshop in Islamabad in 1984. But he would also enjoy sitting in his little stereo room, listening to the amazing Corky Siegel play blues harp with an accompaniment by the Denver Symphony Orchestra. He loved to drive his ancient BMW sports car to Boulder and the mountains, or through the plains or to a ski resort or a Keystone meeting. The car had a hole in the floorboard, big enough to see the pavement below, and fur flying out the windows from his beloved dog, Shanty, standing on the back seat. We loved waking up on crisp Colorado mornings to the smell of his French-press espresso and a croissant from the local walk-to bakery, or to eat in the evening at a close-by Italian or far-away Mexican restaurant. Martin  is sorel


Talisia esculenta Radlk. seedlings and their recovery potential after the resumption of irrigation. Six treatments were performed: irrigation, irrigation suspension, irrigation suspension + silicon at 0.5 g L−1, irrigation suspension + silicon at 1.0 g L−1, irrigation suspension + salicylic acid at 50 mg L−1, and irrigation suspension + salicylic acid at 100 mg L−1. The evaluations were carried out at the beginning of the experiment, at 10 and 15 days after irrigation suspension, when the seedlings showed a photosynthetic rate close to zero, and at recovery. The plants were subjected to water restriction for up to 15 days, then re-irrigated until the recovery point, which was monitored based on the photosynthetic rate. Silicon application attenuated the harmful effects of water deficit on gas exchange and initial fluorescence, promoted proline accumulation in the leaf and root, and provided higher seedling quality. Salicylic acid application contributed to the maintenance of the relative water content of leaves during the water deficit period. Silicon and salicylic acid applications can attenuate the harmful effects of water stress, with silicon being the most effective agent in maintaining its growth and metabolism.Water deficit is one of the factors that most influence plant growth and yield. Thus, this study aimed to evaluate the effect of silicon and salicylic acid application and water deficit on the growth and photosynthetic and osmoregulatory metabolism of  Talisia esculenta Radlk., (Sapindaceae), also known as olho-de-boi, pitomba-do-mato, and pitomba-de-macaco, is a fruit tree native to the Amazon region, found naturally throughout Brazil, is well adapted to the Brazilian Cerrado, and is also found in Bolivia and Paraguay . The leaves were collected in the morning, taken to the laboratory, and cut with cylinders of known area. After weighing the fresh mass, the leaves were placed in a container with distilled water and covered with aluminum foil for 24 h for saturation. After weighing, the saturated disks were dried in a circulation oven to determine the dry mass.Assessed using an OS-30p portable fluorometer . The leaves were subjected to dark conditions for 30 min. Initial fluorescence (F0) and photosystem II photochemical potential quantum efficiency (Fv/Fm) were considered.® CFL 1030 portable chlorophyll meter , with readings on fully expanded leaves.The chlorophyll index was determined using a ClorofiLOGDetermined by spectrophotometry following the extraction proposed by , in whicTo evaluate the quality of the seedlings, the height, diameter, and dry biomass data of shoots and roots were used, and the Dickson quality index—DQI  was calcA, A/iC, Fv/Fm, and DQI, according to the proposal by [Estimated through the phenotypic plasticity index (PPI) of posal by , using tp ≤ 0.05) and the treatments by the Scott-Knott test (p ≤ 0.05) using the software SISVAR [The data were subjected to analysis of variance and, when significant, the means of evaluation periods were compared by the Tukey test (e SISVAR .T. esculenta is found in places with an arid climate, its seedlings were very sensitive to water deficit, with a significant reduction in the photosynthetic rate, stomatal conductance, Rubisco carboxylation efficiency, relative water content in the leaves, and photosystem II potential quantum efficiency, and increased proline content. The seedlings recovered the photosynthetic rate in just seven days after resuming irrigation when treated with Si at 0.5 g L−1 and SA at 50 mg L−1. Our results show that although The seedlings showed a significant increase in the other evaluated characteristics regardless of the application of these mitigators, although they took time to recover the photosynthetic rate or did not recover the values of the other evaluated characteristics in most treatments.−1 is not recommended because it did not allow the recovery of seedling characteristics.The salicylic acid dose of 100 mg L


It has been estimated that 19,880 new cases of ovarian cancer had been diagnosed in 2022. Most epithelial ovarian cancer are sporadic, while in 15%–25% of cases, there is evidence of a familial or inherited component. Approximately 20%–25% of high-grade serous carcinoma cases are caused by germline mutations in the BRCA1 and BRCA2 genes. However, owing to a lack of effective early detection methods, women with BRCA mutations are recommended to undergo bilateral risk-reducing salpingo-oophorectomy (RRSO) after childbearing. Determining the right timing for this procedure is a difficult decision. It is crucial to find a clinical signature to identify high-risk BRCA-mutated patients and determine the appropriate timing for performing RRSO.In this work, clinical data referred to a cohort of 184 patients, of whom 7.6% were affected by adnexal tumors including invasive carcinomas and intraepithelial lesions after RSSO has been analyzed. Thus, we proposed an explainable machine learning (ML) ensemble approach using clinical data commonly collected in clinical practice to early identify BRCA-mutated patients at high risk of ovarian cancer and consequentially establish the correct timing for RRSO.The ensemble model was able to handle imbalanced data achieving an accuracy value of 83.2%, a specificity value of 85.3%, a sensitivity value of 57.1%, a G-mean value of 69.8%, and an AUC value of 71.1%.In agreement with the promising results achieved, the application of suitable ML techniques could play a key role in the definition of a BRCA-mutated patient-centric clinical signature for ovarian cancer risk and consequently personalize the management of these patients. As far as we know, this is the first work addressing this task from an ML perspective. Ovarian cancer is a complex disease that led to 19,880 new cases and 12,810 deaths in 2022. According to the National Cancer Institute, it represents 1% of all new cancer cases and caused 2.1% of all cancer deaths . Most epIn recent years, artificial intelligence and its machine learning (ML) branch have been widely applied to develop decision support systems with the purpose of solving challenging diagnosis and prognosis tasks within the biomedical field , 19. TheWithin this emerging scenario, despite the fact that a plethora of ML models have been designed either to support ovarian cancer diagnosis or to aid clinical decision-making processes in ovarian cancer treatment plannings –25, therrare class will indicate those patients for whom ovarian cancer occurred, while the label abundant class will point out control cases.The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Azienda Ospedaliera Policlinico Consorziale-University of Bari, Italy (protocol code 6398). We integrated clinical features into an ML model to predict the occurrence of ovarian cancer on a cohort of 184 BRCA-mutated patients who underwent RSSO at the Department of Gynecologic Oncology–University of Bari, Italy, in the period between May 2017 and April 2022. After RSSO, adnexal tumor occurrence has been shown in 7.6% of these patients. In particular, a STIC was found in 3.3% of patients, while a diagnosis of invasive ovarian cancer (stage IA–IC) was made in 4.3% of woman. Hence, the resulting dataset we treated was imbalanced. We formulated a binary classification task to distinguish patients for which ovarian cancer have or have not occurred. In the following, the label np had missing value, the algorithm assigns the value of the same feature related to the patient without any missing feature values and whose feature vector comprising all those features without missing values for the patient np had the minimum Euclidean distance from the corresponding feature vector of the patient np. Finally, before data analysis, continuous features were standardized by removing the mean and scaling to unit variance.Multi-ensemble resampled model, since it arose from the integration of two well-known techniques in the field, whose functioning is based on the under-sampling of the abundant class composing the initial dataset (Ensemble Different Resampled Datasets and (ii) Resample with Different Ratios. Technique (i) encompasses the building of n models, which employs all the N samples of the rare class and N randomly chosen samples of the abundant class. Then, all the n models’ predictions are jointed into an ensemble model to obtain a final single prediction per patient. Technique (ii) envisages the development of some models in which samples from the rare and abundant classes are resampled according to different ratios, e.g., ratio 1:1 (rare class:abundant class), ratio 1:2 (rare class:abundant class), and ratio 1:3 (rare class:abundant class). The ratio between the two classes could differently influence prediction  according to the rationale under technique (i). Specifically, a majority voting technique was performed (see vs. rare class) was evaluated by means of suitable statistical tests on all the datasets used to define the 100 resampled models per ratio. Specifically, the Wilcoxon–Mann–Whitney test  as well as accuracy, sensitivity, specificity, and G-mean, were computed to evaluate model performances. While AUC measures the degree of separability of the classes predicted by the classifier, the other metrics, which were defined after the identification of the optimal threshold by Youden’s index on receiving operating characteristic (ROC) curve  curve , are expwhere TP and TN stand for true positive (number of rare cases correctly classified) and true negative (number of abundant cases correctly classified), while FP (number of abundant cases misclassified as rare cases) and FN (number of rare cases misclassified as abundant cases) are false positive and false negative ones, respectively. The geometric mean (G-mean) is usually used to evaluate performances on imbalanced data  since, aindividual explanations, i.e., explanations of the decision-making process underlying the implemented models to make a final decision for individual patients. An individual explanation could be finally evaluated by clinicians to make an informed decision on whether to trust the model’s prediction for that patient  values computation , to prov patient , 37. Therefer to , 37.Multi-ensemble resampled model we proposed here relies on the concept of voting among 100 models for each of three ratios, ratio 1:1, ratio 1:2, and ratio 1:3. For each ratio, the statistical frequency of the features selected by means of the Random Forest algorithm over the training sets of the 100 models developed for each test instance was joined together to obtain an overall statistical frequency of the features for each ratio. p-value< 0.1) returned by the statistical tests. As emerged from The assignment of a test instance to a class by means of the ad-hoc system to handle imbalanced data.The proposed ensemble model achieved promising results: an accuracy value of 83.2%, a specificity value of 85.3%, a sensitivity value of 57.1%, a G-mean value of 69.8%, and an AUC value of 71.1%. 2 and CA-125 = 9.4 are the main features that decrease the risk. For the patient represented in Finally, we explored the application of XAI. Determining the appropriate timing for performing RRSO is a challenging choice. Different series about pathologic findings at RRSO have shown that, in women with a pathogenic BRCA1/2 variant, 4.5% to 9% were found to have occult gynecologic neoplasia, including invasive carcinomas and intraepithelial lesions, through thorough pathologic examinations of their ovaries and fallopian tubes . This reTo the best of our knowledge, this is the first work that tries to fulfill the task of giving an early diagnosis of ovarian cancer in BRCA-mutated patients before the execution of RSSO under an ML angle. Three peculiarities of the model could be underlined. On the one hand, the model functioning is ruled by multi-ensemble approaches, that, as already demonstrated in the state of the art , allow uvs. rare). One future challenge will be to improve the mathematical rules underpinning the model to enhance sensitivity and, as a consequence, accuracy and AUC values. The integration of a wider cohort to analyze with higher performances, especially in terms of sensitivity, as well as with the explanation of the model’s decisions will be the key to develop a non-invasive tool, requiring few easy-to-collect attributes available at first visit, to be effectively used by clinicians. The power of such a tool will consist in identifying the features that could play a key role for the prediction of a specific patient and that can vary from patient to patient, thus defining a patient-centric signature within a global clinical signature. This is the major implication of the model findings on clinical practice recommendations among BRCA 1/2 mutation carriers and specifically on the individual person/patient based on varying personal or family history. However, at this step, in agreement with the goal of this work, we have started to observe the potentiality of the algorithm on two patients as examples (see This study represents a first effort to develop an explainable ML model addressing this task by leveraging the information power of some clinical features referred to a cohort of BRCA-mutated patients undergoing RRSO. However, one limitation of this work is the non-involvement of external validation data, i.e., data provided by other cancer centers. The feasibility as well as generalizability of the proposed model should be further validated on wider cohorts of patients. As the next step of our research work, we intend to apply the model on a cohort of patients, whose data will be yielded by multiple cancer centers and/or hospitals across Italy. This manuscript provides a first attempt to help clinicians categorize BRCA-mutated patients according to their risk of developing ovarian cancer. Although guidelines recommend prophylactic adnexectomy for BRCA1/2 mutation carriers within certain age ranges, there are instances where tumors arise at an earlier age or where patients never develop ovarian cancer at all. These variations can be attributed to diverse factors that influence cancer development. The foundation of the algorithm explored the intricate interplay between multiple patient variables, with a particular focus on understanding their non-linear associations . Despiteples see 5, by juIn conclusion, the present study proposed an explainable ML model that exploits clinical data commonly collected in clinical practice to early identify which BRCA-mutated patients are more prone to an ovarian cancer risk and accordingly determine the appropriate timing for performing RRSO. The promising results achieved are valuable in suggesting how this work could represent the first building block towards the definition of an ML-based decision support system that could be effectively applied in clinical practice. Indeed, our ambitious purpose is to supply to clinicians a user-friendly tool that could return a score representing the ovarian cancer risk for each patient individually, with an intelligible explanation on how the clinical features taken into account for that patient could contribute to the estimated risk.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.Conceptualization, MC, FA, VL, GC, and RM. Methodology, MC and RM. Software, MC. Validation, MC, SB, AF, and RM. Formal analysis, MC, FA, VL, GC, and RM. Resources, RM. Data curation, IR, FA, DL, VL, and GC. Writing—original draft preparation, MC, FA, VL, GC, SB, AF, and RM. Writing—review and editing, MC, FA, VL, GC, SB, AF, DL, IR, FL, AK, AC, and RM. Supervision, GC, VL, and RM. All authors contributed to the article and approved the submitted version.


P < .001, r = −0.37) and the last follow-up  were observed. The Barthel Index was also negatively correlated with ISS at the first visit  and at the last follow-up period . Moreover, ISS was significantly negatively correlated with EQ5d score at the last follow-up . The chi-squared test demonstrated that patients with an ISS of < 14 returned home (P = .03), while those with an ISS of < 19 returned to work (P = .02). ISS is associated with paralysis, activities of daily living, QOL, and lifestyle in patients with SCI and is an important initial injury assessment method.The Injury Severity Score (ISS) is widely used to evaluate patients with multiple injuries. This study investigated the association between ISS and clinical outcomes of patients with spinal cord injury (SCI) in an aging Japanese population. This retrospective cohort study investigated patients admitted to a Japanese university hospital. In the study, 89 patients with traumatic SCI were included. Traumatic SCI was categorized as monotrauma or polytrauma, and the ISS was used to evaluate trauma severity. Spearman’s correlation coefficient was used to estimate the correlation between ISS and the American Spinal Injury Association (ASIA) motor score, Barthel Index (activities of daily living assessment), and the European Quality of Life (QOL) scale (EQ5d) as an assessment of QOL at admission or the last follow-up with the adjustment for age, sex, and body mass index. Return to home and work were analyzed using the chi-squared test after the ISS was divided into three groups . The mean ISS was significantly higher for polytrauma than monotrauma. Significant negative correlations between the ISS and ASIA motor scores at the first visit ( Frankel grade D injuries accounted for most cases (46.3%). The most frequent cause of traumatic SCI was a fall from a level surface (38.6%).The characteristics of patients with spinal cord injury (SCI) in Japan changed between 1992 and 2018 as the population aged. The estimated incidence of traumatic SCI is 49 per million, of which cervical cord injuries were observed in 88.1% of the affected population. Additionally, spinal cord injuries without radiographic abnormalities (SCIWORA) impacted 62% of the affected population. The prevalence of thoracic lesions is higher in SCI patients with polytrauma than in those with SCI alone. Patients with polytrauma have more prolonged hospitalizations and regain activities of daily living at a slower pace. However, neurological recovery is associated with lesion completeness rather than the presence of polytrauma.,3Polytrauma reportedly occurred in 55% of patients with traumatic SCI.,5 A study from Canada reported that the ISS was correlated with the total length of hospitalization and number of days of recumbency. In the same study, SCI was negatively correlated with the Functional Independence Measure score at discharge and 1 to 2 years after injury. In a previous report in the USA, in the acute phase, older patients had a higher ISS, more extended hospitalization periods, lower Glasgow Coma Scale scores, and significantly higher odds of being discharged to an institution rather than home as compared to young individuals. However, the association between the ISS and clinical outcomes in patients with SCI in an aging Japanese society remains unclear. Thus, the current study investigated the association between the ISS and clinical outcomes in patients with SCI at a single healthcare facility in Japan.The Injury Severity Score (ISS) is widely used to evaluate patients with multiple injuries. and was conducted at a single tertiary emergency and critical care center in Japan. Data were collected from the medical records of patients with spinal trauma admitted to our orthopedic department between January 2011 and December 2021. Spinal trauma was diagnosed by surgeons in our department. The exclusion criteria were as follows: age < 18 years at the time of the injury; missing medical record data; comorbidities such as Parkinson’s disease and multiple SCI; no pan-scan examination at admission; and observation period < 365 days. This study included 89 patients who met the inclusion criteria , and external body–the ISS was calculated by adding the squares of the highest Abbreviated Injury Scale grades for each of the three most severely injured body regions. Traumatic SCI can be categorized as monotrauma or polytrauma. Polytrauma was defined using the Newcastle definition: Abbreviated Injury Scale code > 3 in at least 2 body regions. Monotrauma was defined as a spinal injury with an Abbreviated Injury Scale code ≤ 2 in other body regions.The anatomical regions with traumatic injuries were scored and categorized into 9 areas–head, face, neck, thorax, abdomen, spine, upper and lower limbs, and external–using the 2008 Abbreviated Injury Scale by referencing clinical records and computed tomography and magnetic resonance imaging scans at admission. cause of injuries, SCIWORA, ISS, history of surgical treatment of the spine or polytrauma, transfer to a rehabilitation hospital, total length of hospitalization, total rehabilitation term, and observation period.Demographic data included age, sex, body mass index, presence of polytrauma, medical history including ossification of the posterior longitudinal ligament and diffuse idiopathic skeletal hyperostosis, primary injury level, American Spinal Injury Association (ASIA) Impairment Scale, and Barthel Index at admission and the last follow-up period; European Quality of Life Score (EQ5d); living location ; and return to work by the last follow-up.The primary outcomes were the correlation between ISS and ASIA motor scoreU test was used to compare ordinally distributed data (such as age) between the monotrauma and polytrauma patients, and the median and standard deviation (SD) was calculated. The chi-squared test was used to compare the proportions of nominally distributed data (such as sex) between groups. Spearman’s correlation coefficient was used to estimate the correlation between ISS and neurological injury level  or outcomes such as ASIA motor score, Barthel Index at admission or the last follow-up, and EQ5d at the last follow-up after the adjustment for age, sex, and body mass index. Return to home and work were also analyzed using the chi-squared test after ISS was divided into three groups by score  according to a previous study. Statistical significance was set at P < .05. Values are presented as mean ± SD.All statistical analyses were performed using SPSS version 29 . The data were not normally distributed. The Mann–Whitney This study included 89 patients 67 men, 22 women) with a mean age of 62.4 ± 1.5 years . The prevalence of thoracic lesions was significantly higher in the polytrauma versus monotrauma group (P = .006). Conversely, the mean SCIWORA score was significantly higher in the monotrauma versus polytrauma group (P = .03). No significant intergroup difference was observed in the number of patients who underwent spinal surgery.The characteristics of SCI patients with monotrauma and polytrauma are displayed in Table P < .001). No significant intergroup differences were noted in the observation period, total length of hospitalization, or total rehabilitation period. Moreover, the mean hospital stay for acute treatment was significantly longer for the polytrauma versus monotrauma group. .The ISS was significantly higher in the polytrauma versus monotrauma group  lived at home, 11 (12.3%) were in a care facility, and 4 (4.4%) were in a long-term medical care ward at the last follow-up. Within 90 days, 56 patients (62.9%) returned home, while 18 (20.2%) were in a long-term medical care ward. No significant intergroup differences were observed in the proportion of patients who returned home at the final follow-up  were employed at admission, of whom 25 (50.0%) returned to work by the final follow-up. No significant intergroup differences in the proportions of patients who returned to work at the final follow-up were observed  and the last follow-up . The Barthel Index was also negatively correlated with ISS at the first visit  and at the last follow-up . Additionally, ISS was significantly negatively correlated with EQ5d at the last follow-up , while patients with an ISS < 19 returned to work ; moreover, the definition of “polytrauma” was not unified in previous studies. The prevalence of chest and lung injuries with thoracic lesions in SCI patients with multiple injuries was higher than that in patients with cervical and lumbar lesions in Italy. In this study, thoracic and other spinal and limb injuries were common.Of the patients included in this study, 58 (65.1%) were diagnosed with SCI and multiple injuries and 15 (18.0%) met the criteria for polytrauma. The incidence of SCI with multiple injuries in Italy and Germany ranges from 55% to 71%. Possible explanations for this discrepancy may be the different causes of injury .In this study, the mean ISS of patients with SCI in the monotrauma and polytrauma groups was 16.0 ± 1.0 and 25.0 ± 2.5, respectively. A previous study in Japan reported an ISS of 15 in 65.3% of patients with traumatic spine injuries in 2004 to 2013. functional independence measure, EQ5d, return to living at home, and return to work. One possible explanation for the aforementioned associations is that ISS is related to SCI paralysis severity. In this study, 57.0% of the ISS were attributed to spinal trauma. Therefore, paralysis severity was strongly associated with ISS in the monotrauma and polytrauma groups. Regarding SCI paralysis severity, a significant correlation was observed between ASIA motor score and ISS.This study clarified that ISS is associated with paralysis, activities of daily living, quality of life, and lifestyle in the aging Japanese society. In previous studies, ISS was linked to the ASIA motor score, Our study population was in an area subjected to heavy snowfall geographically located in a predominantly farming village district, and 22 (24.7%) patients were injured in agricultural work involving growing apples or shoveling snow. Therefore, our results may not be representative of the general Japanese population. Second, the sample size was small, and we could not separately analyze each lesion level or ASIA Impairment Scale grade, as in a previous study. All 38 patients with ASIA Impairment Scale grade E had spinal fractures; of them, 30 had other injuries. To investigate the ISS distribution, we did not exclude ASIA Impairment Scale grade E. In addition, in a previous study, the proportion of ASIA Impairment Scale grade E in Japan was reportedly 35%; therefore, understanding their outcomes is essential. However, patients with mild limb numbness may not have visited a hospital, which may have affected the results of the analysis. Finally, non-clinical factors, including universal public health and long-term care insurance systems, and welfare services for individuals with disabilities in Japan. This has enabled renovations for those returning home, allowing patients with SCI to receive long-term rehabilitation. Additionally, patients with SCI underwent rehabilitation for a mean of 218.4 ± 36.5 days. Whether the patients were categorized or not, SCI patients with a Barthel Index oer 67.5 points were provided rehabilitation.This study had several limitations. First, the sample consisted of patients at a single emergency and critical care center in Japan and was subject to biased patient selection. The sociodemographic characteristics in this study differed from those previously reported in Japan by Miyakoshi et alIn conclusion, this study investigated the clinical outcomes of traumatic SCI using 10-year data from 2010, the background of which reflects the aging Japanese society. The results suggest that the outcomes of the aging society of Japan can be predicted using ISS evaluations at the time of traumatic SCI.www.editage.com) for the English language editing.The authors thank Drs Hitoshi Kudo and Sunao Tanaka of the Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine for their technical support and valuable discussions. We would like to thank Editage (Conceptualization: Manami Tsukuda, Gentaro Kumagai, Eiichi Tsuda.Data curation: Manami Tsukuda, Gentaro Kumagai.Formal analysis: Manami Tsukuda, Gentaro Kumagai, Eiichi Tsuda.Funding acquisition: Yasuyuki Ishibashi.Investigation: Manami Tsukuda, Gentaro Kumagai, Kanichiro Wada, Toru Asari, Yohshiro Nitobe, Eiichi Tsuda.Methodology: Manami Tsukuda, Gentaro Kumagai.Project administration: Gentaro Kumagai.Supervision: Yasuyuki Ishibashi.Visualization: Gentaro Kumagai.Writing – original draft: Manami Tsukuda, Gentaro Kumagai.Writing – review & editing: Manami Tsukuda, Gentaro Kumagai, Eiichi Tsuda, Yasuyuki Ishibashi.


BackgroundThe morbidity and mortality rates related to hypertension (HT) are still high despite the developments in this area. Nondipper hypertension (NDHT) is related to worse clinical outcomes. But the dipping pattern of HT is not still used for treatment targets. In this study, we investigated the effect of dipping patterns on coronary artery disease (CAD) complexity evaluated by the SYNTAX score (SS).MethodologyPatients with stable CAD and HT were included in the study. All patients were monitored with 24-hour ambulatory monitoring, and dipping patterns were evaluated. Coronary artery complexity was determined by SS for all patients and compared along with different dipping patterns.ResultsP = 0.003). The mean SS between the DHT group and the NDHT group (P = 0.03) and between the DHT group and the RDHT group (P = 0.01) was significantly different. The less decrease or increase in mean blood pressure (MnBP) values was significantly correlated with high SS.A total of 331 patients with HT and stable CAD were evaluated in the study. The mean age of the patients was 62.6 ± 9.9 years, and 172 (52%) were male. The number and percentage of patients with dipper HT (DHT), NDHT, over-dipper HT (ODHT), and reverse-dipper HT (RDHT) were 89 (26%), 143 (43%), 11 (3%), and 88 (26%), respectively. When the groups were compared according to SS, the SS of the patients with RDHT were significantly higher (the SS were 6.33, 4.99, 3.09, and 2.7 for RDHT, ODHT, NDHT, and DHT, respectively, ConclusionsNDHT, especially the reverse dipping pattern, is closely related to complex CAD. Meticulous consideration of dipping patterns can identify high-risk patients and improve clinical outcomes. Hypertension (HT) is the most common chronic disease and one of the most important causes of cardiovascular (CV) morbidity and mortality. Despite advances in diagnosis and treatment, deaths and complications related to HT are not well controlled . The mosA 10% to 20% decrease in BP during sleep is considered physiological and is defined as dipper HT (DHT). A decrease of less than 10% is defined as nondipper HT (NDHT) and has been associated with increased CV mortality. Patients with a decrease in BP of more than 20% during sleep are called over-dipper HT (ODHT), and patients without a decrease but an increase in BP are called reverse-dipper HT (RDHT). Various studies have shown that CV risks are also increased in these patients -8.This study aims to reveal the relationship between the dipping pattern and the severity of CAD in patients with HT. For this purpose, this study was designed to compare the dipping pattern and SYNTAX score (SS); a higher score is indicative of more complex CAD and poor CV prognosis in hypertensive patients .www.syntaxscore.com)  5.38, 95% confidence interval [CI] 1.995-14.539; The results of this study showed that the SS was significantly different in various dipping patterns in patients with controlled HT. SS was highest in the RDHT group and lowest in the DHT group. The presence of DM and SS were independent predictors for NDHT.The association between HT and CV risk is well known. The effect of diurnal BP changes on adverse events has also been shown ,11. But The SS is an important indicator of CAD severity, complexity, and prognosis. The relationship between HT and SS is well known. This study revealed the relationship between dipping status and SS in patients with HT. However, these findings did not reveal a cause-effect relationship. The results suggest that complex CAD may be a cause of adverse clinical events in patients with NDHT and contributed to the need to consider the dipping pattern, not HT alone, in the risk classification of CAD. The findings of this study contributed to the need to consider the dipping pattern, not HT alone, in the risk classification of CAD. Re-evaluation of the dipping pattern after coronary revascularization may reveal a cause-effect relationship. The number of patients in the reverse dipper and over-dipper groups were lower. Data on these patients are also limited in the literature ,19. SimiThe nondipper rate was found to be 67%. Although this rate was very high, it was similar to previous data in the literature -22. In tIn previous studies, the presence of DM, old age, decreased kidney functions, and the presence of left ventricular hypertrophy was found to be the independent factors associated with nondipping patterns, and only DM and SS were independent predictors in our study. The exact mechanism of NDHT is not known exactly, but many extrinsic and intrinsic factors are thought to affect it. Physical activity, neurohormonal regulation, nutritional factors, salt consumption, DM, chronic kidney disease, and sleep apnea are some of them . The nonAll patients in this study were under treatment for HT. Despite this, the rate of ND pattern was quite high. Previous studies revealed that the ND pattern was seen at similar rates, whether patients are under treatment or not . AlthougLimitationsThe findings of this study should be interpreted with limitations. First, it was a single-center, cross-sectional study with a relatively low number of patients, which precluded the generalization of the results. However, the majority of the results were similar to the literature. A single 24-hour ABPM measurement for determining dipping patterns was another limitation. Technical doubts are also important restrictions for 24-hour ABPM measurements. The mean SS was low in the entire population. It would be more appropriate to evaluate the results in a wider SS range.Nondipping and reverse dipping patterns are common and closely related to more complex CAD among HT patients. Known prognostic effects on outcomes and the clinical usefulness of dipping patterns in managing HT are limited. This study showed that CAD is more complex among patients with nondipping patterns than dipping ones. Dipping patterns may help determine high-risk patients and optimize treatment goals. The foremost deficiency is that the diagnosis of the dipping pattern is not objective enough. Further studies are needed in this regard.


The present study aimed to analyze the impact of deforestation on the malaria distribution in the Lao People’s Democratic Republic (Lao PDR), with consideration of climate change.Malaria distribution data from 2002 to 2015 were obtained from the Ministry of Health of Lao PDR and each indicator was calculated. Earth observation satellite data  were obtained from the Japan Aerospace Exploration Agency (JAXA). Structured equation modeling (SEM) was conducted to clarify the relationship between the malaria incidence and Earth observation satellite data.p < 0.01). With global warming steadily progressing, forested areas are expected to play an important role in the incidence of malaria in Lao PDR. This is believed because malaria in Lao PDR is mainly forest malaria transmitted by Anopheles dirus.As a result, SEM identified two factors that were independently associated with the malaria incidence: area and proportion of forest. Specifically, malaria was found to be more prevalent in the southern region, with the malaria incidence increasing as the percentage of forested land increased  and in low-temperature areas adjacent to malaria-endemic areas, where the vegetation is similar to that in malaria-endemic areas. Anopheles mosquito, whose bite transmits malaria from human to human  were obtained. Forested area data were obtained from land cover products developed by the Climate Change Initiative (CCI) of the European Space Agency (ESA); the LST and precipitation for 2002–2015 were obtained from the Japan Aerospace Exploration Agency (JAXA) and Japan’s Public Health Monitoring and Analysis Platform (JPMAP) . The JPMFinally, structured equation modeling (SEM) was performed to determine the relationship between malaria incidence and Earth observation satellite data. QGIS 2.18.22 was used to analyze the geographic data, and SPSS 24.0 and Amos 24.0 were used for statistical analyses.f), Chi-square (CMIN), and comparative fit index (CFI). According to conventional criteria, a good fit was defined as CMIN/df < 2, and CFI > 0.97, and an acceptable fit was defined as CMIN/df < 3, and CFI > 0.95 [First, a descriptive analysis was conducted to gain an overview of the malaria incidence , climate change (LST and precipitation), and deforestation  in Lao PDR. Second, SEM was used to identify the factors associated with API. The correlations of all variables were examined and a path model was constructed based on the results of a bivariate analysis. The fit of the model was examined in terms of degree of freedom  Fig. .Fig. 1MaP. falciparum in 2000, but in 2015, cases from P. vivax exceeded in number. Mortality had declined dramatically.In 2015, 36,056 malaria cases were identified  of forested land disappeared from 2002 to 2015. This rate of deforestation was higher than that in Lao PDR as a whole . On the other hand, the annual deforestation rate had a tendency to decrease year by year until 2015 . After excluding data from the capital city, the final model identified two factors that were independently associated with the API: area and the proportion of Forested land . As the proportion of forested land declined, precipitation decreased and LST increased (p < 0.01). The southern region, where malaria is most prevalent, had a higher proportion of forest, higher LST, and more precipitation in comparison to the other regions (p < 0.01). The average LST continued to significantly increase each year (p < 0.01). Contrarily, the area of forested land has decreased nationwide in Lao PDR, mainly where the proportion of forests was originally high (data not shown). An analysis using forest rates and satellite images also suggested that the areas with increased forest were considered to be plantations, artificially zoned agricultural land in 0.5-km squares.Specifically, malaria was more prevalent in the southern region, and the malaria incidence increased as the proportion of forested land increased . In Lao PDR, Anopheles (A.) dirus and A. minimus, which were found in forested zones, were known to be the primary malaria vector mosquitoes [With global warming steadily progressing, forested land was expected to play an important role in malaria incidence in Lao PDR. In the present study, SEM identified two factors that were independently associated with API: area and the proportion of forested land. Specifically, most malaria cases occurred in the southern region, and the malaria incidence increased as the proportion of forested land increased , which prefer forest edges and agricultural lands, may enter into the new ecosystem causing the re-emergence of malaria.The results of this study, conducted in the Asian nation of Lao PDR, are consistent with the established epidemiological theory that deforestation reduces the risk of malaria in Southeast Asia , 18. In ed areas . AlthougP. knowlesi [P. knowlesi should become endemic among people in Lao PDR.The present study’s analysis of forest coverage and satellite images suggested that the areas of increased forest coverage were actually plantations divided into 0.5 km squares (data not shown). A major challenge in Asia is the lack of information on at-risk populations, which include individuals living or working in or near forests where malaria vectors are present , 22. In knowlesi , is esseknowlesi . With thAdditionally, in the malaria-endemic areas of Lao PDR, the average surface temperature was higher than 22.5 °C, a temperature suitable for the growth and survival of vector mosquitoes. In fact, the LST was higher in the capital city, where malaria was not endemic. One possible explanation is that in addition to climate factors such as temperature, vegetation influences the distribution of malaria. In the present study, this was demonstrated by SEM.P. falciparum, from the country by 2024. Since 2004, the first-line treatment for P. falciparum in Lao PDR has been artemisinin-based combination therapy (ACT) [P. vivax cases in Lao PDR involves a 3-day course of ACT along with a single low dose of primaquine only. This is because G6PD testing and the 14-day primaquine treatment to prevent relapses in P. vivax cases are available only in a limited number of hospitals in the county. Therefore, it can be inferred that the introduction of the ACT alone will not reduce the number of P. vivax cases to the same extent as it does for P. falciparum cases.Furthermore, Lao PDR has set a goal to eliminate the lethal malaria parasite, py (ACT) . The curAlthough global warming in the southern region is more moderate than that in the capital city and Lao PDR as a whole, global warming in the southern region may increase malaria endemicity at the boundaries of malaria-endemic areas, such as Sekong, where surface temperatures are lower than in the southern region . While t


Human adenoviruses (HAdVs) are common viruses that can cause local outbreaks in schools, communities and military camps, posing a huge threat to public health. An ideal POCT device for adenovirus detection in resource-limited settings is critical to control the spread of the virus. In this study, we developed an integrated and electricity-independent sample-to-answer system that can complete nucleic acid extraction, amplification, and detection at room temperature. This system is suitable for field and on-site detection because of its rapidity, sensitivity, lack of contamination, and lack of requirements of high-precision instruments and skilled technicians. It consists of two separate modules, ALP FINA  and SV RPA . The extraction efficiency of ALP FINA can reach 48 to 84%, which is close to that of the conventional centrifuge column. The detection sensitivity of SV RPA is close to 10 copies/μL of AdvB and AdvE without aerosol contamination after repeated operations. When SV RPA was applied to the detection of nasopharyngeal swab samples of 19 patients who were infected with AdvB or AdvE as well as 10 healthy volunteers, its sensitivity and specificity reached 100%, respectively.IMPORTANCE HAdV infections are readily transmittable and, in some instances, highly contagious. Early and rapid diagnosis is essential for disease control. In this work, we developed a portable, disposable, and modularized sample-to-answer detection system for AdvB and AdvE, which rendered the entire test to be completely independent of electricity and other laboratory infrastructure. Thus, this detection system can be applied in resource-limited settings, and it has the potential to be further developed as an early diagnosis method in the field. Human adenovirus (HAdV) is a common infectious pathogen that can cause large outbreaks in closed environments, especially in military camps and schools –4. The e–As sample preparation is the first step in nucleic acid-based testing, an extraction method that is simple, rapid, portable, and independent of electricity is essential for field applications of NAAT. The use of paper-based nucleic acid extraction techniques has recently emerged for POCT, involving the use of a specifically designed membrane for filtration by selectively retaining the DNA from lysed samples . HoweverIn addition to sample preparation, the rapid amplification and visual detection of samples is critical to the realization of NAAT-based POCT. In this respect, isothermal amplification technologies can achieve the rapid amplification of pathogens at room temperature , among w11–16–To meet all of the requirements for a fully integrated point-of-care NAAT system that is suitable for resource-limited settings, we combined the two independent working modules of ALP FINA and SV RPA into a sample-to-answer system. The ALP FINA module utilizes the alkaline lysis method, combined with a Fusion 5 membrane, to achieve nucleic acid purification, and this does not require heat or centrifugation. The SV RPA module utilizes the visualization advantages of the RPA-LFD assay, which can be efficiently carried out at room temperature, making the entire process electricity-independent. Thus, the system would be suitable for field applications and rapid diagnosis in community clinics.Adenovirus (Adv) infection is a frequent cause of respiratory diseases in China . There a2 = 0.931 and 0.992, respectively. Despite the correlation of the traditional method being slightly stronger than that of the ALP FINA module, the extraction efficiencies of the two methods were not significantly different.  Sensitivity and specificity. The serial dilutions of AdvB and AdvE DNA from 106 copies/μL to 1 copy/μL were used for the threshold detection of the SV RPA and qPCR. The results demonstrated that AdvB and AdvE could be simultaneously detected via SV RPA, using the universal primer pairs with the same sensitivity of 10 copies/μL, and these results was similar to those of the qPCR method (R method . The proR method .(ii) Temperature and time optimization. The results showed that the detection could be effectively operated at a range of temperatures from 25°C to 45°C  Sealing. There were no false-positive results in multiple repetitive experiments with SV RPA that were conducted in a separate room. In contrast, the traditional open mode of the RPA-LFD assay yielded false-positive results in the negative control in the third and subsequent experiments. This result demonstrated that the SV RPA device has reliable sealing that could effectively prevent aerosol contamination , an independence from expensive equipment, trained personnel, and external power, and no contamination by aerosolized nucleic acid. However, the current methods of realizing sample-to-answer mostly apply to microfluidic strategies. Wang et al. proposed an automated microfluidic system that depended on PCR. The system integrates the sample preparation area, amplification area, and product analysis area into one sample channel. The sensitivity of the system to detect HPV is 200 copies/test . Tian etIn this study, we constructed two independent modules of ALP FINA and SV RPA that are based on paper-based extraction and RPA-LFD, respectively, and integrated them into a system that could realize nucleic acid extraction, amplification, and visual detection. As to the ALP FINA module, we improved the paper-based nucleic acid extraction and replaced the enzyme lysis with alkaline lysis, which omits the steps of centrifugation and heating and is not dependent on equipment. Subsequently, the portable nucleic acid extraction chamber was designed to further simplify the operation procedure. The ALP FINA module not only reduces cost and simplifies the steps but also has an approximate extraction efficiency that is comparable to that of a traditional centrifugal column, endowing it with great advantages in field applications. The RPA-LFD technology can be operated at room temperature with impressive advantages, such as high sensitivity, good specificity, rapid reaction, and electricity-independence, making it ideal for field detection , 27. HowMoreover, this type of modularized system provides additional flexibility, given that both modules are compatible with a variety of technologies , 29. ForAmong the 7 recognized HAdV species (A to G), species B and E are likely to cause acute respiratory infections and easily break out in special groups, such as kindergartens , 30, schCultured 293 cells infected with AdvB, 14 AdvB-infected nasal swab specimens, and 5 AdvE-infected nasal swab specimens were originally obtained from the Fifth Medical Center of the Chinese PLA General Hospital. AdvB and AdvE plasmid standards, targeting the hexon gene from nucleotide 27 to 254, were produced by Sangon Biotech .12 copies/μL. The standard gradient dilutions, which contained AdvB nucleic acid ranging from 102 to 109 copies/μL, were performed via spiking into different amounts of nasopharyngeal swab specimens from healthy volunteers.A preliminary experiment demonstrated that the quantity of AdvB DNA that we obtained from 200 μL of the AdvB-infected cell suspension was about 2 × 10(i) ALP FINA prototype. The housing of the ALP FINA device is comprised of a top cover with a sample inlet channel that is 0.5 cm in diameter and a bottom cover with a waste outlet channel that is 1.0 cm in height (n height  and 5. T(ii) SV RPA prototype. The SV RPA device consists of a storage column, loading rubber stopper, seal rubber stopper, open/close switch, reaction tube, and LFD ( and LFD  and 7. T(i) ALP FINA operation. The operation of the ALP FINA device for DNA extraction is described in (ii) SV RPA operation. Recombinase polymerase amplification and visual detection used the SV RPA prototype, as shown in After the addition of the reaction components, we sealed the device by closing the switch and incubated the device at 35°C for 15 min. After the incubation, pressure was applied on the stopper to rapidly increase the air pressure in the pressurized chamber. As a result of the pressure increase, the RPA amplification solution and the LFD running buffer flowed out of the reaction tubes through the microsized pores into the detection chamber. These liquids could be collected at the slanted surface of the flow channel, mixed at the card slot, and reacted once in contact with the LFD.(iii) Complete prototype operation. The ALP FINA and SV RPA modules were combined to complete the DNA extraction, amplification, and detection steps (on steps . Nucleicon steps .(i) ALP FINA. ALP FINA was compared to the traditional centrifugation extraction method using a QIAamp DNA Minikit . Both methods were applied to extract DNA from equal volumes (200 μL) of reference strains with serial dilutions. Subsequently, the DNA extractions were quantified via quantitative PCR (qPCR), using ABI 7500 software v2.0 . In each qPCR run, the standard curve was generated via the calculation of the average cycle threshold value and a logarithm of the AdvB DNA standard dilution. The effective viral DNA concentration was quantified via standard curve differences.(ii) SV RPA. The sensitivity of the SV RPA was evaluated using dilutions of AdvB and AdvE DNA plasmid standards and was compared with the results of qPCR. The specificity was confirmed with DNA samples from five other species . Given the importance of the reaction temperature and the time in point-of care testing (POCT), the optimal temperature was determined by performing the reaction in thermostats in temperatures ranging from 20°C to 50°C for 20 min each. The optimal reaction time was determined by stopping the reactions performed at 35°C at 0, 5, 10, 15, 20, and 25 min.(iii) Sealing verification. To evaluate the sealing integrity of the SV RPA device, repeated experiments were performed in a separate room and compared to the traditional open-operation mode, referring to the standard operating procedures of molecular laboratories. Using 106 copies/μL of AdvB DNA and nuclease-free water as the positive and negative controls, respectively, the experiment was repeatedly performed twice a day for five days under the two conditions described so as to monitor the occurrence of false-positive results.AB330084, AB330085, AB330088, AB330092, AB330095, AB330097, AB330102, AB330115, AB330116, AB330131, and KF911353) were used for DNA detection as a target sequence. The universal primers for the simultaneous detection of both Adv types were designed using Primer 5.0, based on the alignment of these sequences and on the identification of type-specific conserved regions. Several primer pairs were evaluated, and one primer combination was eventually determined to be optimal. The primers for SV RPA and qPCR are described in The hexon gene of AdvB and AdvE from GenBank . Probit regression was used to determine the limit of detection and its 95% confidence interval.


The reward value of a comfort meal was measured on different days: at initial exposure, after aversive conditioning  and after a cognitive intervention (disclosing the aversive conditioning paradigm in the test group vs. no explanation in the control group). The primary outcome, digestive wellbeing, was determined using graded scales at regular intervals before and after ingestion. Results: At initial exposure, the comfort meal produced a rewarding experience that was impaired using aversive conditioning; upon re-exposure to the original meal, the cognitive intervention increased meal wanting and liking; improved digestive wellbeing and mood; tended to reduce postprandial satiety, bloating/fullness; and abolished discomfort/pain, thereby restoring the hedonic value of the comfort meal. By contrast, sham intervention had no effects, and the postprandial sensations remained like the responses to the offending meal. Conclusion: In this proof-of-concept study, we demonstrate that in healthy women, a mild, short-term acquired aversion to a comfort meal can be reversed using a cognitive intervention. ClinicalTrials.gov ID: NCT05897411.Background: Aversive conditioning weakens the gratifying value of a comfort meal. The aim was to determine the effect of a cognitive intervention to reverse aversive conditioning and restore hedonic postprandial response. Methods: This was a randomized, sham-controlled, single-blind, parallel study that was conducted on 12 healthy women ( Ingestion of a meal induces sensations that persist during the postprandial period in parallel to digestion, and these sensations are key to ingestive behaviour . The posWe hypothesized that acquired food aversion may be reversed using deconditioning. In this context, the term deconditioning refers to reversal of previously conditioned behaviours, i.e., unlearning aversive conditioning ,5. To teFunctional gastrointestinal disorders, the most prevalent diagnoses in gastroenterology, represent a spectrum of conditions characterized by altered interaction between the gut and the brain. This group of disorders is distinguished by gastrointestinal symptoms related to various potential mechanisms, including disturbances in gastrointestinal motility, heightened visceral sensitivity , altered mucosal and immune functions, alterations in gut microbiota, and modifications in central nervous system (CNS) processing of gut-derived stimuli . SpecifiA single-blind, sham-controlled, randomized parallel study investigating the impact of a cognitive intervention on the aversive response to a meal was conducted from January to May 2023.Participants were informed that the study aimed to assess how meal composition influenced their eating experience, and that various hummus recipes with different ingredients would be tested. Participants were randomly assigned to the cognitive intervention group or the control group by means of a computerized random sequence generator. First, both groups underwent aversive conditioning, and, subsequently, the effects of the cognitive intervention were compared to a sham intervention. The research adhered to the Declaration of Helsinki and was conducted in accordance with a preapproved protocol by the Vall d’Hebron Institutional Review Board 338/2016N approved on 28 October 2016, and revised on 19 February 2021), and all were informed and provided consent before the commencement of any study procedures. ClinicalTrials.gov registration number NCT05897411.2, or any form current dieting of selective eating . Only candidates that liked hummus were enrolled in this study. Candidates filled out a standard abdominal symptom questionnaire , the Hospital Anxiety and Depression Scale  without obesity and weight stable were enrolled in this study. Participants were recruited through public advertising, and only those who met the entry criteria (see below) were chosen for enrolment. For this proof-of-concept study, we exclusively enrolled female participants to maintain uniformity and align with recent data indicating that women, in comparison to men, exhibit greater sensitivity to conditions influencing the experience after the meal . Candidarequired ); Dutch required ) and theA previous study demonstrated a decrease in postprandial satisfaction through aversive conditioning (the area under the curve for digestive wellbeing changed by −186 ± 68 score × min in the test group vs. 16 ± 19 score × min in the control group) . Based oDuring the study period (4 days), participants were asked to refrain from intense exercising and to consume a typical evening meal every night, consisting of 100 g of chicken, 50 g of rice, 50 g of white bread, and 1 apple . After an overnight fast, they were instructed to consume a standard breakfast consisting of 200 mL of coffee with milk (semi-skimmed) and a sandwich made with 50 g of white bread, 30 g of ham, and 40 g of cheese  four hours before presenting to the lab for each study session. All participants stated that they adhered to the protocol. Digestive sensations were assessed at regular intervals during fast (referred to as the pre-ingestion period), during meal consumption itself (the ingestion period), and during the 60 min following the end of the meal .The meal was served at 20 °C and comprised 200 g hummus , 26.7 g toast , and 120 mL mineral water. Following a stepwise procedure, the meal was administered, divided into four equal servings, with each serving presented every 180 s. Each portion consisted of 50 g of hummus along with 6.6 g of toast, which was placed on a platter. Following each serving, 60 s were designated for participants to evaluate their digestive sensations (as described below). The entire ingestion process lasted for 16 min, and participants could consume the 120 millilitres of water at their own pace throughout the ingestion period. Two recipes of hummus were administered, either with regular fat content . The hummus (regular or high-fat) was either coloured using 1.9 g of a pink colourant that is soluble in fat and is devoid of odour and flavour  or non-coloured. To match the lipid content of the coloured meal, the hummus on days 1 and 4 were supplemented with 1.9 g of sunflower oil. The fat content of the hummus and the amount of food to be served were decided upon after a series of initial feasibility studies.Participants completed four experiments conducted on consecutive days, as follows: First day: a comfort meal (tasty hummus with regular fat content and non-coloured) was administered. Second day: an offensive meal (high-fat coloured hummus) was administered to induce aversive conditioning. Third day: proof of aversive conditioning by administration of a coloured hummus with regular fat content. Fourth day: a cognitive intervention was performed in the test group, but not in the control group, and the initial comfort meal  was administered afterwards. The cognitive intervention disclosed the experimental paradigm as follows: participants in the test group were informed that on the 2nd study day, the meal was modified with a hidden fat overload  plus a colour additive, while on the 3rd study day, only the colorant was added to the original comfort meal . The effWe employed five scales of 10 cm with gradations from −5 to +5 in order to assess the following aspects: (a) meal wanting (ranging from impossible to eager), (b) meal liking (from very disagreeable to very agreeable), (c) hunger/satiety (ranging from extremely hungry to completely satiated), (d) digestive wellbeing (varying from extremely unpleasant sensation to extremely pleasant sensation), and (e) mood (ranging from negative to positive). Scales also of 10 cm but graded from 0  to 10 (very much) were used to assess for (f) abdominal bloating–fullness, (g) discomfort–pain, and (h) nausea. Meal wanting was assessed both at the presentation of each serving (inquiring about the desire to consume that portion) and at the conclusion of the entire meal (inquiring about the desire for another portion). Meal liking was evaluated after eating each portion (how much did you like it). The other scales were evaluated (a) before meal ingestion, at 5 min intervals, during the 10 min preceding ingestion (pre-ingestion period); (b) during the meal consumption (ingestion period), following each meal serving; and (c) after the meal , initially at 5 min intervals for the first 20 min, and subsequently at 10 min intervals up to 60 min following the end of ingestion  of that period by the adjusted score . To derive the overall AUC (expressed as a product of score and minutes), the sum of the areas from all observation periods was determined.In each participant, the impact of the high-fat meal was calculated as the difference in the AUC on the second day  minus the first day ; the effect of aversive conditioning was quantified as the difference between the third day  and the first day , and the effect of the cognitive intervention was quantified as the difference between the fourth day (postintervention) and the third day . For graphic representation of the data, average values and standard errors for the recorded variables within each group were calculated and are presented in the figures below.t-test (either paired or unpaired). In cases where the data distribution was not normal, paired data were analysed using the Wilcoxon signed-rank test and unpaired data using the Mann–Whitney U test.We conducted statistical analyses both within each group and between the groups. The normality of data distribution was determined using the Shapiro–Wilk test, which determined the normal distribution of data. For normally distributed data, we employed Student’s A sensitivity analysis to control for individual variations and confounders whilst obviating the need for artificial divisions between normally and nonnormally distributed data was included. The data were analysed for each day of the experiment, treatment groups were compared on the sensation score outcomes using generalized linear mixed modelling (GLMM), with time (in minutes), intervention group and time—intervention group interaction terms included. To take into account the correlation between each individual patient’s responses over time, we included the individual as a random effect. Visual inspections of residual plots were used to determine deviations from normality. In the absence of normality, robust variance estimators were calculated.The SPSS Statistics package for Windows  was used for all calculations , except the generalized lineal mixed models, which were calculated using R studio version 4.1.2.All co-authors reviewed the data and provided approval for the final version of the manuscript.2 (range 19.8–23.9). On the physical anhedonia scale, their average score was 15.3 ± 1.7 in the (range 6–24) all were non-smokers. Baseline characteristics were not different between groups. All participants adhered to the instructions, completed the study protocol, and were analysed.The average age of participants was 29.9 ± 2.7 years of age (range 19–44 years). Their body mass index averaged at 21.3 ± 0.5 kg/mDuring the pre-ingestion period, participants scored in the questionnaires a sensation of hunger with positive mood, neutral digestive wellbeing, and no sensation of abdominal fullness/bloating, nausea, or discomfort/pain . Particip = 0.491); however, with further ingestion, meal liking and wanting decayed , and at initial taste, meal liking was rated similar as the comfort meal . It had lesser impact on mood (p = 0.386), and resulted in increased homeostatic sensation, particularly satiety (p = 0.008) and fullness/bloating (p = 0.010) accompanied by mild abdominal discomfort (0.003) and without nausea (p = 0.435), mood , satiety , bloating/fullness , abdominal discomfort , nausea .Following the consumption of the high-fat coloured meal  the day prior, both the meal wanting and meal liking of the regular-fat meal, labelled with the same colour, noticeably declined in comparison to the preconditioning exposure to the same meal on the initial study day  (p < 0.001), meal liking , digestive wellbeing , and mood , and the differences were not statistically significant for satiety , fullness/bloating , abdominal discomfort , or nausea .The cognitive intervention reverted the effects of aversive conditioning and restored the original responses to the comfort meal observed at initial exposure on study day 1 . Indeed,ctively) . The effOverall, the results of the sensitivity analysis confirmed the effect of the intervention in the same direction for all the outcomes evaluated. Significant differences in the responses between groups were detected only during the fourth day of the experiment. The full analysis is presented in Our proof-of-concept study demonstrates that a cognitive intervention, under certain circumstances, may revert conditioned food aversion, and restore the reward value of an originally pleasant meal in healthy women.The probe meal in the present study, a tasty hummus, induced the pleasant response characteristic of a comfort meal. Aversive conditioning was achieved by administration of the same hummus containing a hidden fat overload that did not affect its organoleptic characteristics, specifically the palatability, but induced an aversive postprandial response. After this experience, subjects became conditioned and reacted to the original comfort meal mimicking their response to the offending meal. In the test group, the cognitive intervention reverted conditioning through an unlearning process and restored the original response to the comfort meal. By contrast, in the control group, the response to the originally comfort meal, particularly meal wanting and liking, further deteriorated through re-exposure, suggesting that some degree of aversive reinforcement took place.Taste aversion and aversive conditioning of the postprandial experience, both in nonhuman animals and in humans, as in the present study, can be acquired after a single conditioning trial ,14 in coDisclosing the prior conditioning paradigm, and realization of the true situation, resulted in unlearning and reversion of conditioning. We have previously shown that, using a cognitive–sensory intervention, healthy subjects learn to heighten their hedonic response to a comfort meal . InteresBased on previous experience , the proOur conditioning paradigm involved a colour clue , but we cannot ascertain whether the colour clue influenced the effect of the intervention. However, in the control group, the response to the regular-fat meal on the fourth day induced an aversive response even without the colour label, indicating that conditioning was not colour-specific. It has been previously shown that other forms of conditioning affect related stimuli by a phenomenon of generalization ,21.An important contribution of our study is the focus on the postprandial experience over taste. Taste aversion in nonhuman animals function as a protective mechanism to prevent ingestion of potentially noxious foods ,3,14; hoDue to the exploratory nature and complexity of the study, the sample size was small, and in line with previous study, only women were included, as they are more susceptible to conditioning. Additionally, the cognitive intervention was tested on a relatively mild aversive conditioning model and was applied shortly after the acquisition of aversion. Therefore, as a proof-of-concept study, these results need to be interpreted with caution. Our findings cannot be generalized to demonstrate the effectiveness of the cognitive intervention on a larger population, including men, and on stronger and longer-lasting food aversions remains to be established.The relevance of our study lies in the potential application of unlearning aversive conditioning in clinical practice. Symptoms in patients with functional digestive disorders may originate from aversive conditioning, leading to hypersensitivity and hypervigilance ,7,8,9, a


Hypertension (HTN) is a condition that affects nearly half of the adult population in the United States. HTN is the elevation of blood pressure (BP) 130/80 mm Hg or higher. Untreated high blood pressure may increase the risk of myocardial infarction, stroke, and other serious complications. BP over 180/120 mm Hg with end-organ damage is called a hypertensive emergency. Despite advancements in medicine and treatment options, the global burden of HTN has been increasing due to the advancing age of the population and an increasing prevalence of obesity. Non-pharmacological management of HTN has gained prominence worldwide due to its additional benefits and positive impact on the overall health of individuals, having almost no side effects and reducing the financial burden of medication expenses. This article has compiled studies like systematic reviews, meta-analyses, and randomized controlled trials and reviewed the role of non-pharmacological management of HTN, including lifestyle modifications like exercise, weight loss, dietary interventions like dietary approaches to stop hypertension (DASH) diet, low sodium diet, limiting alcohol consumption, smoking cessation and stress management to help control blood pressure. However, non-pharmacological interventions should be initiated in an early phase, and for proper management of HTN, we may need to include both pharmacological and non-pharmacological interventions. This article explored and integrated various studies to highlight the role of non-pharmacological interventions to manage HTN. We also examined the need for more research studies for strategies to alleviate morbidity and mortality associated with HTN. By 2025, hypertension (HTN) is estimated to affect one-third of the world's population . AccordiAccording to the American College of Cardiology and the American Heart Association, BP is divided into four general categories Table .HTN affects people with advancing age. It is more common in ethnically African and South Asian communities . Major rAccording to the American College of Cardiology, a BP higher than 180/120 mm Hg is considered a hypertensive emergency or crisis. Patients with these blood pressures need emergency medical help. Untreated high BP may increase the risk of myocardial infarction, stroke, and other serious complications. Monitoring BP every two years, starting at age 18, is important to diagnose and treat hypertension timely to prevent complications. HTN is diagnosed by performing repeated careful measurements of blood pressure. Blood pressure is categorized as follows: Normal blood pressure, defined as systolic blood pressure (SBP) less than 120, and diastolic blood pressure (DBP) less than 80. An elevated BP is an SBP of 120 to 129 and a DBP of less than 80. HTN is defined as a systolic pressure more than or equal to 130 or a diastolic pressure more than or equal to 80.One of the quintessential steps to manage HTN is lifestyle modifications like exercise, weight loss, dietary interventions, a low-sodium diet, limiting alcohol consumption, smoking cessation, and stress management to help control BP. The treatment of HTN is based on specific characteristics like stage of disease, compliance, and comorbid conditions. For proper management of HTN, we may need to include pharmacological and non-pharmacological interventions . DespiteThis article aims to emphasize the non-pharmacological management of HTN as it is an attractive approach to dealing with HTN in developed and developing countries due to the economic limitations and having additional benefits with few or almost no side effects . AnotherHigh BP can lead to complications like coronary artery disease, congestive heart failure, end-stage renal disease, and stroke . A studyConsidering aspects like cost, effectiveness, and the potential for side effects of antihypertensive medications, lifestyle interventions Table , includiWeight lossWeight loss is one of the most important non-pharmacological interventions to lower BP. Numerous interrelated pathophysiologic mechanisms stimulate higher BP in obesity . In overIntermittent fasting (IF) is an effective way to lose weight and thus helps lower blood pressure . The mec2 showed that IF helped lower BP with a p-value of 0.51 [2 revealed that 12 weeks of IF helped lower SBP (p = 0.254) and DBP (p = 0.570) [2 who followed IF for eight weeks showed a lowering of SBP (p<0.001) and DBP (p<0.05) [2, showed a lowering in SBP (p<0.05) and DBP (p<0.05) [Assorted studies have shown that IF lowers BP. Harvie et al., in their study involving 107 overweight or obese premenopausal women, showed that IF for six months helped lower SBP (p = 0.99) and DBP (p = 0.84) . Varady  of 0.51 . A study= 0.570) . In a stBP p = 0.4 and DBP(p<0.05) . Erdem e(p<0.05) . Practicality of ImplementationAlthough weight loss plays a significant role in lowering BP, it may be challenging to stay constantly motivated for long-term results . DevelopDietAfter originating in the 1990s, the dietary approaches to stop hypertension gained popularity in lowering blood pressure . The DASThe DASH diet has been funded by the National Institute of Health (NIH) in various research projects to know whether specific dietary interventions helped treat HTN . The subDASH recommends the consumption of: Healthy carbohydrates like green leafy vegetables , whole grains , low-glycemic-index fruits, legumes, and beans ; HealthyAccording to a study by Ozemek et al., healthy diets like DASH dietary patterns have been shown to decrease SBP by 11 mm Hg in hypertensive individuals and by 3 mm Hg in normotensive individuals. Ideally, the goal is to reduce sodium to <1500 mg/dl, but it is good to aim for at least a 1000 mg/day reduction, which has been shown to reduce SBP approximately by 5/6 mm Hg in hypertensive individuals and by 2/3 mm Hg in normotensive individuals [Hinderliter et al. performed the Exercise and Nutrition Interventions for Cardiovascular Health (ENCORE) study, a trial that involved observing the persistence of lifestyle modifications in 144 overweight participants with higher-than-normal BP for 16 weeks, randomly assigned to the DASH diet alone (DASH-A), DASH diet plus weight management (DASH-WM), or usual care . IndividThe Mediterranean diet (Med Diet) has also helped lower BP. As per the Maine-Syracuse Longitudinal Study conducted in the United States in 2020 by a group of researchers who followed 851 US older adults, for every one unit increase in the Med Diet score in participants, it was found that there was a corresponding reduction of 0.69 units in SBP, a reduction of 0.33 in DBP, and a reduction of 0.45 on mean arterial pressure (MAP) . AlthougPracticality of ImplementationPatients can find it increasingly difficult to maintain long-term dietary changes like low caloric intake, low salt intake, and limiting processed foods, which in turn may lead to a shift towards preintervention practices in some individuals, for example, increased calorie intake . This imExerciseIncreased physical activity has been advocated as the first-line intervention for preventing and treating patients with prehypertension and as a treatment strategy for patients with stage 1 or stage 2 HTN, according to the Duthe American College of Sports Medicine, the United States Joint Nations Committee on Prevention, Detection, Evaluation, and Treatment of High BP, the World Health Organization and International Society of Hypertension, and The National Heart Foundation . ExercisThe pathogenesis of HTN involves oxidative stress. Another mechanism involved is the decreased bioavailability of nitric oxide (NO) . PhysicaThe following four randomized controlled trials have been conducted to show that exercise helped lower both systolic and diastolic BP in participants: In the meta-analyses of randomized controlled trials conducted by Fagard et al., 72 trials have been conducted with an average of 40 participants per trial, which involved a 16-week study of 40 minutes of exercise sessions three times/week with an average intensity of 65% of heart rate . This stPracticality of Implementation Patients may be initially motivated to engage in exercise programs but can find it challenging in long-term maintenance, which may lead to weight regain . In ordeAlcoholThe health effects of alcohol intake are variable and are based on the amount of intake  and intake pattern  -47. In tAccording to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), low-risk drinking is considered four drinks per day or less than fourteen drinks per week for men and less than or equal to three drinks per day and less than seven drinks per day for women . Binge dAccording to a study performed by Fuchs et al. in 2021, it has been found that, especially in women, the risk has been found to start at moderate alcohol consumption, and alcohol withdrawal has been found to promote the reduction in BP in short-term trials . Suliga Briasoulis et al., in their meta-analysis of 16 prospective long-term studies, revealed that alcohol consumption of more than 20 g per day increases the risk of HTN significantly in women, whereas consumption of 31 to 40 g in men significantly increases the risk of HTN . NeverthIt should be taken into consideration that the effects of alcohol are not similar in all individuals . Also, iSmokingSmoking is an important risk factor for HTN. The following is the mechanism involved in the elevation of BP by smoking Figure .Physicians play a key role in encouraging and helping patients achieve smoking cessation . HTN hasPsychological stressPsychological stress is another contributor to HTN . Stress LimitationsIn this study, we focused on HTN as a single factor and outlined the management; however, we have not taken into consideration other comorbidities like diabetes and hyperlipidemia that may co-exist with HTN. Although various impactful studies were integrated, this study could not examine and evaluate all the available data. This study does not address the challenges with adherence to lifestyle modifications like exercise and dietary interventions, as well as the challenges with compliance with limiting alcohol and cessation of smoking. Although non-pharmacological management alone can be effective in patients with prehypertension or stage 1 HTN, however, for stage 2 HTN, pharmacological management is still considered the first line. Furthermore, this study did not outline the combined effects of medications and lifestyle modifications.It is evident that uncontrolled HTN can lead to serious complications like myocardial infarction, stroke, end-stage renal disease, and other manifestations of end-organ damage. In summary, the clinical implication of this review article is to establish a strong emphasis on the management of essential HTN with non-pharmacological interventions involving multiple elements of lifestyle modification, focusing on more permanent measures to help improve the overall quality of life and to decrease physician dependence and hospitalizations for serious complications. Weight loss is the most beneficial non-pharmacological intervention to manage HTN, followed by the DASH diet, exercise, alcohol, smoking, and management of stress. These should be initiated in the early phase and used along with pharmacological intervention only to be highly effective. Clinicians play a crucial role in explaining the risks of untreated HTN to patients and strongly encouraging them regarding long-term adherence to lifestyle interventions like weight loss, exercise, lowering alcohol consumption, and smoking cessation. The use of mobile technology and personal digital devices can be effective to help track and maintain healthy lifestyle changes like weight loss and exercise, especially when support and accountability through active intervention are not available. Even though various studies have been performed, more in-depth research studies need to be conducted to master the approach to minimize morbidity and mortality associated with HTN.