Purpose: Acute pancreatitis (AP) which is distinguished by local pancreatic necrosis, followingby systemic organ failure is known as an inflammatory disease. Up to now, there are only a fewtreatment options accessible for patients suffering from AP. In this study, we aimed to examinethe anti-inflammatory capacities of human bone marrow-derived mesenchymal stromal cells(hBM-MSCs) in a detailed AP model experiment.Methods: AP was induced in C57BL/6 mice by intraperitoneal administration of cerulein (100μg/kg/h × 7 doses) at intervals of 1 hour. Then, 2×105 MSCs were infused in the AP mice bytail vein 6 hours after the last cerulein injection. Mice were sacrificed 12 hours following theinjection of hBM-MSC, and blood samples and pancreas tissues were obtained.Results: We first determined the presence of transplanted hBM-MSC in the pancreas of micewith AP, but not the control mice. Our data indicate that administration of hBM-MSCs to micewith AP lead to (i) decreased serum levels of amylase, lipase and myeloperoxidase activities, (ii)downregulation of proinflammatory cytokine, macrophage inflammatory protein 2 (MIP-2), and(iii) upregulation of the anti-inflammatory cytokine, interleukin 10 (IL-10). Moreover, hBM-MSCadministration results in notably attenuated cerulein-induced histopathological alternationsand edema.Conclusion: we demonstrate that hBM-MSC attenuates AP signs and indicating that hMB-MSCtherapy could be a suitable approach for the treatment of inflammatory disease such as AP. Severe AP is a major challenge for clinicians, and the mortality in this group of patients is 25-30%. Many reports have clearly revealed that unnatural activation of pancreatic enzymes initiates the majority of pathological cascades processes that finally lead to edema and histopathological changes in pancreatic tissue. In addition, many inflammatory cytokines, such as monocyte chemoattractant protein 1 (MCP-1), chemokine (C-X-C motif) ligand 2 (CXCL-2), interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) are produced by macrophages, lymphocytes and other immune cells, predominantly in pancreatic tissue. These cytokines are accountable for initiation of the inflammatory cascade that can lead to the destruction of other organs. Many pathological and biological aspects of AP have been recently discovered, but only a few treatment options for these patients are available. Although several remedies for the treatment of AP have been developed in past two decades, mortality has not significantly declined, indicating that development of new therapeutic options is necessary for treatment of patients with AP.Acute pancreatitis (AP), as an important inflammatory illness, presents clinically from mild and self-limiting to severe and necrotizing disease. They are able to differentiate into various cells and rapidly renew themselves, making these cells a suitable candidate for regenerative medicine and tissue repair. Accordingly, MSCs have been utilized to cure different inflammatory diseases, such as myocardial infarction, acute kidney failure and collagen-induced arthritis. So far, several studies have determined methods of isolating MSCs from different sources, including various components of fetal tissue and adult tissue . Among the various sources of MSCs, bone marrow-derived MSCs (BM-MSCs) are regarded as the main source and most commonly applied in the clinical applications. Although the majority of clinical and preclinical examinations administered autologous/allogeneic transplantations, some studies utilized xenogeneic MSCs to treat various disorders in animal models. The purpose of this study was to investigate the anti-inflammatory effects of human bone marrow-derived (hBM)-MSCs in cerulein-induced AP in a mice model. Our data demonstrate that hBM-MSCs and their secreted factors could ameliorate the AP signs probably through their immunomodulatory and regenerative effects.Mesenchymal stromal cells (MSCs) has the capability to possess immunosuppressive and immunomodulatory properties.Thirty-two mice of the C57BL/6 strain were purchased from Pasteur Institute  and kept in the animal house of the research center, under standardized conditions. Mice were 6-8 weeks old with average weight of 25-30 g at the time of experimentation. At least 72 hours before beginning of the experimentation, mice were carried to the laboratory to allow for acclimatization to the environment. All animal experiments were approved by the Institutional Animal Care and Research Ethics Committee of Kurdistan University of Medical Sciences, Sanandaj, Iran. Briefly, mice were distributed into four groups (n:8 for each group) randomly. One group was injected with normal saline intraperitoneally at intervals of 1 hour (×7), which was considered the control group (Ctrl). AP group (AP), was injected cerulein  at intervals of 1 hour (×7). Additionally, two other groups of mice were included: the Ctrl-MSC and AP-MSC, which received 2 ×105 hBM–MSCs through tail vein 6 hours after the last injection of normal saline or cerulein, respectively.Experimental AP was induced by cerulein as formerly reported. Mononuclear cells were isolated by gradient centrifugation at 2500 rpm for 30 minutes on Ficoll-PaqueTM Plus . Mononuclear cells were then plated at a concentration of 10-30 × 103 cells/cm2 in Dulbecco’s Modified Eagle Medium (DMEM) containing 20% (v/v) of FBS. Non-adherent cells were removed 2 days later, and fresh medium was added. When the cultures reached 80-100% confluence, hBM-MSCs were trypsinized and subcultured. The purity of hBM-MSC suspensions was evaluated by flow cytometry using the following monoclonal antibodies: CD105-PE, CD45-FITC and CD90-PerCP, along with corresponding isotype controls . Finally, the suspensions were analyzed utilizing a BD FACS CantoTM flow cytometry System .In order to prepare hBM-MSCs, bone marrow aspirate was harvested from the iliac crest of a normal donor who was negative for HIV, HBV and HCV laboratory tests, after informed consent was obtained. Then, hBM-MSCs were cultured and isolated as previously reported.5 hBM–MSCs through tail vein by insulin syringes (28 gauge) 6 hours after the last normal saline (Ctrl-MSC) or cerulein (AP-MSC) injection. 12 hours after injection of hBM-MSCs the mice were scarified by cervical dislocation after anesthesia , and the bloods (500-1000 µL) were collected by a direct intracardiac puncture.Human BM-MSC administration was performed under anesthesia . Mice received 2×10Pancreatic tissue was removed promptly and shared in several parts, either fixed in formalin for histopathological examinations or frozen at -70°C for polymerase chain reaction (PCR) analysis. DNA was extracted from 20 mg of pancreatic tissue using Prime Prep Genomic DNA Isolation Kit (Genet Bio Kit) according to the manufacturer’s instructions. A pair of human-specific primers  describing a 219 bp region of cytochrome B mitochondrial gen was designed by Gen Runner software. PCR reaction was performed with 2X PCR master mix and included an initial step of denaturation at the temperature of 95°C for the duration of 10 minutes followed by 35 cycles  in the clinical chemistry laboratory .The fresh pancreatic tissue was collected from each group of mice, and pancreatic edema was determined as previously reported.Formaldehyde-fixed  pancreatic tissue was embedded in paraffin, sectioned (5 µm) and stained using hematoxylin-eosin (H&E) to evaluate infiltration of inflammatory cells and acinar cell injury or necrosis. Ten randomly selected sections for each tissue sample were analyzed after staining. Histological evaluation of pancreatic sections was performed by pathologist collogues (B.N), who was blinded to each group. Tissue samples initially had frozen at -70°C and were thawed at 4°C. The tissues were then homogenized in 20 mmol/L phosphate buffer (PH 7.4) and centrifuged . The consequential pellet was resuspended with 0.5% hexadecyl trimethyl ammonium bromide (Sigma-Aldrich) in 50 mmol/L phosphate buffer (PH 6.0). The suspension was exposed to four freeze-thaw cycles and further sonicated (40 seconds on ice). The sample was again centrifuged . MPO activity in the obtained supernatant was determined using TMB liquid substrate system for ELISA at 405 nm with the Tecan spectrophotometer plate reader. The results were corrected for the absorbance per mg of tissue weight (A°/mg) in the respective samples and expressed as an increase over the control group.Neutrophil sequestration within the pancreatic tissue was evaluated by assessing the tissue myeloperoxidase (MPO) activity.Finally, determination of the expression of inflammatory cytokines in pancreatic tissue was assessed using by RT-PCR. RNA was isolated utilizing RNA extraction kit  and RNA was transcripted into cDNA utilizing of Bioneer kit . Amplification was conducted in a thermocycler . The PCR profile consisted of an initial denaturation for 5 min (94°C), followed by 40 cycles for 30 seconds (95°C) and annealing temperature for each gene (30 seconds) and the final step for 45 seconds (72°C). The PCR produces were electrophoresed on a 2% agarose gel comprising ethidium bromide. ImageJ software was employed for the densitometry analysis of the gel bands. The following primers were used: mouse MIP-2  and mouse IL-10 . Mouse ß actin  was used as a housekeeping gene.P < 0.05 demonstrated statistical significance.Numeral data are displayed as mean ± SD of 8 mice. One-way ANOVA and Tukey post hoc test was utilized to determine the difference between groups and To isolate hBM-MSCs, we discarded the non-adherent cells, and cultured the adherent cells as described in the previous section. After 3-4 days of culture, hBM–MSCs showed features distinct from other adherent cells (adherent hematopoietic cells and monocytes). They were spindle-shaped cells or fibroblast-like cells and had morphology resembling epithelial cells . In the Next, in order to examine the presence of hBM-MSCs in pancreatic tissue, PCR assay was employed to detect human cytochrome B gene. As shown in In this study, the severity of cerulein-induced AP was distinguished by elevated levels of both amylase and lipase in the serum of mice. Also, levels of these enzymes were evaluated after treatment with hBM-MSCs. As presented in the The MPO activity was evaluated to quantify the extent of neutrophil and monocyte accumulation in pancreatic tissue and demonstrate the extent of inflammatory cells infiltration in tissue. As shown in As inflammation and its players, such as proinflammatory cytokines, associate to the pathobiology of AP, we inspected the effect of hBM-MSCs on the expression levels of two important mediators in pancreas tissue. We observed that the expression of MIP-2 was upregulated in mice with AP, but its expression was significantly decreased in the group that was treated with hBM-MSCs . In cont However, recent findings indicate that MSCs, due to their immunomodulatory capacity, could be a suitable candidate for immunotherapy of many inflammatory disorders, including AP. In this study, we investigated the anti-inflammatory effects of hBM–MSCs on an AP model of mice and observed that transplanted MSCs significantly decrease enzymatic activities of serum amylase and lipase, as well as decreasing other pancreatitis indications, including edema, MPO activity, and pancreatic pathological changes.Although a number of biological and pathological aspects of AP as an inflammatory disease have been recently discovered, and many therapeutic approaches have been offered to the patients, the full recovery in 25-30% of patients with severe AP not yet been evaluated. Moreover, we have recently shown that intratracheally administration of human umbilical cord vein MSCs results in attenuation of pulmonary fibrosis in a mouse model. Although the routes of administration in our previous and current work were different, the MSCs still exhibited immunomodulatory activity. Herein, we used human cytochrome B DNA as a marker to determine the presence of hBM-MSCs in the pancreas of mice with AP after treatment with these cells and found that the amount of xenogeneic genome was much higher in the AP mice than the control group, indicating that hBM-MSCs migrated to the inflamed tissue of the pancreas. Since MSCs exhibit immunomodulatory properties, they are able to evade immune system recognition. Moreover, they possess a very low level of MHC-class I, implying that hBM-MSC not only could not be recognized by the exogenic host but also may mediate immunomodulatory activities. It has also been reported by Jung et al that the severity of tissue injury can influence both migration and function of MSCs after transplantation, demonstrating that injured tissues may chemoattract MSCs to the site of inflammation.Mounting evidence indicates that MSC migrates to the injured tissue to either repair or reduce the inflammatory cascade. To participate in tissue repair, MSC needs to cooperate and interact closely with stromal and inflammatory cells, implying that MSC should migrate from circulation or other sources toward the damaged tissue. Gong et al showed that SDF-1 is upregulated in the pancreatic tissue of rats with induced-AP, and the SDF-1/CXCR4 axis regulates the trafficking of MSC towards the pancreas as the migration of these cells was blocked by anti-CXCR4 antibody or the CXCR4 inhibitor (AMD3100). In addition, another report has exhibited that CXCR4 is expressed at high levels in the bone marrow and ischemic tissues but disappears from MSC surface after cultivation. However, hypoxia and proinflammatory cytokines can restore CXCR4 levels. Taken together, we postulate that increased levels of many pro-inflammatory cytokines and hypoxia-induced state in the injured pancreas could upregulate both SDF-1 and CXCR4, resulting in hBM-MSC leaving circulation to enter the inflamed pancreas.The migration process of MSCs is mainly dependent on chemokine attraction. A key player in this process is stromal-derived factor (SDF-1), and via binding to its receptor, CXCR4 has a significant role in the migration of MSCs. Data collected for this study demonstrate that hBM–MSCs treatment results in a reduction of serum amylase and decrease of lipase levels, as well as pathological alternations of AP, indicating that hBM-MSCs have beneficial effects on experimental models. Accordingly, Yang et al showed that umbilical cord MSCs alleviated severe AP disease in a rat model in a time-dependent and dose-dependent manner. They proposed that earlier utilization of MSCs, with appropriate doses after induction of severe AP, more effectively helps alleviate the consequence of pancreatitis. Since transplanted MSCs cannot differentiate into other cells in a short time span, the hypothesis has emerged that MSCs regulate immune responses through paracrine effects. In accordance with the results obtained in the current study, others have previously reported that the administration of MSC attenuated AP in animal models. AP was induced by sodium taurocholate in rat models in most of those studies, however, our study is the first study using hBM-MSCs to treat cerulean-induced AP in mice model. Data from our laboratory confirm these notions that, at least in the case of AP, hBM-MSCs cannot differentiate into other pancreatic cell types and more likely attenuate the AP symptoms and findings by decreasing inflammatory cascades in the pancreas. We have observed that the infusion of 2×105 cells of hBM-MSCs 6 hours after AP induction significantly decreases lipase, amylase, and MPO activity, in addition to creating histopathological alterations. However, injection of hBM-MSCs at 12 hours and 24 hours after AP induction did not display a significant effect (data was not shown). So far, we propose that hBM–MSCs can have a beneficial influence in the treatment of AP if these cells are utilized at the optimal time. Based on the fact that the majority of AP in human are self-limited in nature, cellular therapy using hBM–MSCs would not be a therapeutic option. However, either hBM–MSCs or their derived mediators could be suitable approaches for the treatment of severe AP and autoimmune AP.AP is the outcome of inopportune activation of proenzymes within acinar cells and following this process, the levels of digestive enzymes immediately increase in patient serum. We administered experimental AP by cerulein injection, which is a typical animal model of AP that induces pancreatitis signs similar to AP disease in human. MIP-2 is a robust chemoattractant for neutrophils in mice and participates in leukocyte trafficking as the migration of neutrophils reduced in MIP-2-/- mice. By employing flow cytometry analysis, we previously demonstrated that the number of pancreatic neutrophils is remarkably increased in mice with AP, which is associated with the levels of MIP-2. Accordingly, we exhibit that the expression of MIP-2 is considerably enhanced in the cerulein-induced AP, confirming the previous study. However, the administration of hBM-MSCs into the tail vein of the mice with AP resulted in a considerable reduction in the expression of the inflammatory MIP-2 in pancreatic tissue. IL-10 is known to have an important role in the balance of immune function and it has been stated that MSC accelerates tissue repair in experimental models by enhancing the IL-10 levels. Interestingly, our data show that the expression of IL-10 at mRNA levels was downregulated in AP mice, then upregulated after treatment with hBM-MSC. This is in agreement with a recent report, showing that the endoscopic administration of MSCs reduces inflammation in experimental colitis. Based on our data and previous observations, we envision that hBM-MSCs may restore the imbalance of pro-inflammatory/anti-inflammatory cytokines during AP.Mounting evidence from previous reports implies that the accumulation of neutrophils into pancreatic tissue is governed by the interaction of chemokines and their receptors.This study demonstrates that hBM-MSCs are able to inhibit inflammatory reactions and improve damaged tissue of the pancreas in mice models of AP disease. Although this work confirms that cell therapy using hBM-MSCs at the optimal time could be a functional approach to treat AP mice, further investigation employing physically larger animals is required before making any clinical conclusion for humans. Moreover, understanding new mechanisms of hBM-MSC effects in pancreatitis and investigation of MSCT progress in AP remains for the further relevant study.A grant (grant no. 14/10693) from Kurdistan University of Medical Sciences (KUMS) was offered to AJ. TM was an MSc student in medical immunology at KUMS.All animal experiments were approved by the Ethics Committee of Kurdistan University of Medical Sciences, Sanandaj, Iran .The authors declare that there is no competing financial interest.


Most implantations of left ventricular assist devices (LVAD) are performed inlow-volume centers. This study aimed to evaluate the procedural learningcurve of HeartMate II (HM2) implantations by comparing outcomes between twotime periods in a low-volume center.All 51 consecutive patients undergoing HM2 implantation between January 2009and December 2017 were reviewed and allocated into 2 groups: early-era group and late-era group . Theprimary outcome was the 90-day mortality rate, and the secondary outcome wasa composite of mortality, neurological event, reoperation for bleeding, needfor temporary right ventricular assist device, and pump thrombosis at 90days. Median follow-up time was 51 months (0-136). A cumulative sum (CUSUM)control analysis was used to establish a threshold of implantations thatoptimizes outcomes.Patients in the early era had a higher rate of diabetes, previous stroke, andinotrope support before HM2 implantation. The 90-day mortality rate was notsignificantly higher in the early era , but thecomposite endpoint was significantly higher . The CUSUManalysis found a threshold of 23 operations after which the compositeendpoint was optimized.Patients undergoing HM2 implantation in a low-volume center have improvingoutcomes with number of cases and optimized results after a threshold of 23cases. Significant changes in patient selection, surgical techniques, andpatient management might lead to improved outcomes after LVADimplantation. Many patients are either ineligible to hearttransplantation (HT) or unable to wait for a graft due to a declining condition.CF-LVAD therapy is now recommended for selected patients with end-stage heartfailure, either as a bridge to transplantation (BTT), bridge to candidacy, ordestination therapy (DT).The use of continuous-flow left ventricular assist devices (CF-LVADs) in themanagement of patients with end-stage heart failure has been increasing over theyears-7. For this reason, current coverageby the Centers for Medicare & Medicaid Services requires a surgeon with at least10 CF-LVAD implantations in the past three years. Optimal volume thresholds remain controversial, but someauthors suggest an optimal volume ranging between 20 and 50 annual implantations percenter,6. Better outcomes reported in high-volume centersmay be related to patient selection, established processes for surgical management,postoperative care, and long-term medical follow-up. Others have shown that the advantage ofhigh-volume centers should be accounted for by surgeon volume. The necessity of volume thresholdshas also been disputed in favor of evaluating centers by demonstratedoutcomes.Several studies have shown that outcomes after CF-LVAD implantation are related toannual center volume. It is important tounderstand outcomes in low-volume centers as 43% of patients in the United Statesreceive a CF-LVAD implantation in a center with <30 implantations peryear.In Canada, there is no true recommendation regarding volume thresholds for CF-LVADimplantation. In Quebec, the Institut National d’Excellence en Santé et enServices Sociaux requires a minimum of 10 implantations of CF-LVAD every three yearsto provide certification for a center. During the last eight years, <30 patientsper year got a CF-LVAD implantation in the province of Quebec among three cardiaccenters, the number of CF-LVAD patients varying from 0 to 11 depending on the centerand yearGiven the prevalence of low-volume centers, studying outcomes in the face of thiscontingency is important to understand what can be improved with increasing numberof cases. This study therefore aims to evaluate outcomes of HeartMate II™ in a low-volume center by investigating the impact of thelearning curve on implantations.This retrospective observational study was approved by the Institutional ReviewBoard. All 51 consecutive patients who underwent HM2 implantation at theinstitution between January 2009 and December 2017 were reviewed. Preoperativecharacteristics, including demographics, medical history, clinical status atadmission, biological parameters, echocardiography, and right heartcatheterization were studied. Perioperative and postoperative data, includingoperative durations, concomitant procedures, postoperative complications,hospital length of stay (LOS), intensive care unit (ICU) LOS, and causes ofdeath were also examined. Data were collected from electronic medical records,patients’ hospital charts, and clinical follow-up. Data collection ended inSeptember 2020. Median follow-up was 51 months (0-136 months) and was 100%complete.Patients were allocated into two groups based on timing of HM2 implantation toassess the impact of the learning curve on outcomes: the early-era group (from2009 to 2014) (n=25), or the late-era group (from 2015 to 2017) (n=26). Thecutoff point between years 2014 and 2015 was chosen arbitrarily as it coincidedwith reaching half of the total surgical case volume and thus allowed us tocompare two groups with similar sample sizes.. All patients underwent a median sternotomy. Apreperitoneal pocket was created and the driveline was tunneled through therectus muscle before heparin injection. Cardiopulmonary bypass (CPB) was used inall cases, but the aorta was clamped only if a concomitant intracardiacprocedure was needed . The “core then sew” method was performed inall cases and 12 sutures of 2-0 Ethibond were placed in a pledgeted,interrupted, horizontal mattress fashion to attach the apical cuff. The inletcannula was positioned within the left ventricle and the pump was placed in thepreperitoneal pocket. The outflow graft was sewn in the ascending aorta in allcases. After deairing through the outflow graft, the patient was graduallyseparated from CPB, and the pump speed was progressively increased underechocardiographic guidance. Operative data are presented in The implantation technique of the HM2 remained constant throughout this study andwas consistent with previous descriptionsi.e., stroke ortransient ischemic attack), reoperations for bleeding, need for a temporaryright ventricular assist device (RVAD), and pump thrombosis. The 90-daytimeframe was chosen because this is the period during which adverse outcomesafter CF-LVAD implantation are more likely to occur, after which the risksdecrease.The primary endpoint was all-cause mortality. One-year and 4-year survival rateswere examined. Early outcomes were defined as complications occurring during theimmediate postoperative hospitalization or within 30 days of implantation. Acomposite endpoint was used to examine adverse outcomes at 90 days, includingmortality, documented neurological events (Data are presented as mean±standard deviation (SD) or as median and rangefor normally and non-normally distributed continuous variables, and asfrequencies with percentages for categorical variables.To compare the two groups, univariate analysis was performed using chi-squaretests for categorical variables, unpaired t-tests for continuous variables withequality of variances, and Mann-Whitney U tests for continuous variables withoutequality of variances. Actuarial survival curves were estimated using theKaplan-Meier method and were compared between subgroups using the log-ranktest.. This allows the graphical representation ofthe accumulated difference between the observed outcome and the target outcome.In this study, when the composite endpoint  was reached for a case, a sharp increase is observedin the graphic, whereas when a case does not reach the composite endpoint, thisexpected outcome is represented by a decrease in the curve.A cumulative sum (CUSUM) control chart was used in order to assess trends inpostoperative outcomes throughout this studyStatistical analyzes were performed using GraphPad  and SPSS . All analyzes wereconducted at a significance level of 0.05.vs. late: n=13, 50%;P=0.47).Pre- and perioperative characteristics of patients in the two eras are presentedin Patients in the early era had a higher rate of diabetes and lower rates ofbeta-blockers and loop diuretics. Their rate of previous stroke was also doublethat of the late era, but the patients had comparable modified Rankin Scales inboth groups. Most of the strokes were thought to be cardioembolic in nature andassociated with a concomitant diagnosis of atrial fibrillation. Primarydiagnosis, Interagency Registry for Mechanically Assisted Circulatory Support(INTERMACS) profiles, biological and echocardiographic parameters and rightheart catheterization values were similar between the two eras. CPB time wassimilar between the two eras, whereas more patients required a concomitantcardiac procedure in the late era.vs. late: n=5, 19%), and 3 patients underwent pumpreplacement in the late era. Twenty-four patients (47%) underwent HT, with nodifference between the two eras .In-hospital outcomes and complications in the two eras are presented in vs. n=9, 35%; P=0.02) .The composite endpoint of 90-day mortality, reoperation for bleeding, need fortemporary RVAD, neurological dysfunction, and pump thrombosis was significantlyhigher in the early-era group compared to the late-era group  . Howevervs. 39±20 months, P=0.05), theduration of HM2 support was not different .Despite a longer follow-up in the early era (57±41 monthsP=0.06). Fourpatients (16%) died after HT in the early era. The main contributing causes ofdeath were multiple organ failure, major bleeding, stroke and right heartfailure and did not differ between the two groups . Many other studies have previously demonstrated that agreater volume of patients correlates with decreased risk of adverse outcomes, withsome suggesting that a center should have between 20 to 50 annual implantations percenter,4-7,9. This was reinforced by theinclusion of center volume in the HM2 Risk Score as a significant risk factor for90-day mortality. Low-volume center in their case was defined as centers with <15implantations during the trial. However, the notion that the learning curve couldinfluence outcomes is important. With improvements in hospital processes, there canbe reductions in rates of acute kidney injury and infection. Likewise, adherence tothe PREVENT study recommendations regarding implantation technique, anticoagulationregimens, and pump speeds can reduce incidence of pump thrombosis. Additionally, the concept ofheart failure teams with specialized clinicians managing these patients improvesoutcomes in mechanical circulatory support, including in low-volumecenters.The association between the quality of outcomes and the cases volume has been shownin several cardiac surgery subspecialties. In an INTERMACS analysis, Cowger etal.versus 84% (P=0.34) and56% versus 46% (P=0.15) respectively. In addition, we observed a dropin composite endpoint incidence between the two eras. This is consistent with thefindings from Mussivand et al., who found that total center volume correlated with outcomes,while annualized frequency did not. Possible factors for the improvement in outcomesare patient selection and surgical technique. Between the two eras, there was aconcurrent change in patient selection towards patients with less comorbidities andwith a more optimized medical therapy which may have improved outcomes. Thesechanges may be part of the institutional learning curve in the management of thesepatients. As for surgical technique, the HM2 was the sole CF-LVAD device used in ourcenter during the study period, thereby allowing greater focus on mastering thisdevice. In addition, reoperation for bleeding was the likely driver of the compositeendpoint between the two eras. This may be related to one of two changes. First, thesurgical team may have become more comfortable with medical management of certainbleeds, hence reducing the number of returns to the operating room. Second, we haveimplemented multiple measures over the years to decrease the rate of postoperativebleeding: achieving a more meticulous intraoperative hemostasis and a lessaggressive anticoagulation strategy .Otherwise, the surgical steps and operative technique have not changed between thetwo eras. This is similar to other cardiac surgery procedures which improve with theprocedural learning curve, such as Ross procedures, minimally invasive mitral valvesurgery, and frozenelephant trunk operations.Our center had an annual volume of approximately 4 implants per year in the early eraand 6.5 implants in the late era. As a result, it is a very low-volume center with<10 implants per year. Despite this low annual procedural volume, our outcomesremain comparable to those reported in the INTERMACS database, with similar 1-yearand 5-year survivals, 78% . The 8th annualINTERMACS report has shown that the survival rate in patients with a BTT and DTdevice strategy at implantation were 85% and 75%, respectively, at one year and 76%and 62%, respectively, at two years in the early era of the registry. This discrepancy did not changemuch with time depending on the era of implantation. Again, this compares to our own cohort which hadan overall survival of 78% at one year.In the secondary analysis, patients who had a CF-LVAD implant as DT were older andhad a lower survival rate. This lower survival rate in patients with DT is wellknown in the literature and was highlighted in previous INTERMACS reports. The HM2is therefore progressively replaced in favor of these better-performing devices indeveloped countries. This was the case in our center, which has stopped HM2implantation in 2018. Results like those reported in this study remain important inthe wider picture of international cardiac surgery. Indeed, there remains asignificant unmet need for cardiac surgery in developing countries, in which costs,among other factors, become a limiting factor for access to healthcare. As such, the improvement inoutcomes with the HM2 based on the learning curve is encouraging given its futureuse primarily in low-volume centers around the world.With the constant renewal of medical technology, there is a gradual shift towardsnewer generation CF-LVAD devices such as the HeartMate 3, which presents betteroutcomes than the HM2.These include patient selection and referral, patient comorbidities, medicaloptimization before CF-LVAD implantation, surgical technique, immediate pre- andpostoperative management, and the expertise of the team involved in themanagement of these patients. Our study did not adjust for all the changes thatcould have occurred during the study period and the difference in outcomes mightbe related to the difference in patient characteristics in addition to thelearning curve effect. Most CF-LVAD implantations were performed by a singlesurgeon, and these results might be attributable to their personal learningcurve.This study carries all the limitations of a retrospective single-center studywith a small number of patients. There may therefore be under-reporting ofcertain outcomes such as driveline infection if these events occurred in anotherhospital center and were not reported in the patient files at our institution.The two eras have been arbitrarily separated in the middle of the study periodaccording to number of implantations. The HM2 is a second-generation pump thatis no longer used in most ventricular assist device centers. Outcomes afterCF-LVAD implantation are highly related to many factors that might not beincluded in our studyIn our experience as a low-volume center, the learning curve influences postoperativecomplications, but not survival, in HM2 implantation with a threshold of 23 casesfor optimized results, possibly through improvements in patient selection andsurgical technique. Patients undergoing HM2 implantation for BTT also had betterlong-term outcomes than patients who underwent HM2 implantation for DT, likely dueto less comorbidities in the former.


There are limited recent data on the characteristics of inflammatory bowel disease (IBD)-associated colorectal cancer (CRC) and the use of colonoscopy prior to CRC diagnosis among persons with IBD. We analyzed IBD-CRC characteristics, survival after IBD-CRC diagnosis and the use of colonoscopy prior to IBD-CRC diagnosis over time.We identified individuals with and without IBD from the University of Manitoba IBD Epidemiology Database and CRC from linkage to the Manitoba Cancer Registry. We compared characteristics of IBD-CRC and sporadic-CRC using logistic regression and survival after CRC diagnosis using Cox regression analysis. We assessed rate and predictors of colonoscopy use 5 years to 6 months prior to IBD-CRC.1,262 individuals with CRC were included (212 IBD-CRC). IBD was associated with an increased risk of death after CRC diagnosis in 2004–2011  but not in 2012–2017 . In the 5 years to 6 months prior to IBD-CRC (1989–2018), 51% underwent colonoscopy, which was very similar to IBD without CRC and contrasted to 9% among sporadic CRCs. Exposure to colonoscopy pre IBD-CRC remained stable through the study period . Exposure to colonoscopy pre-IBD-CRC was not associated with improved post-CRC survival.The risk of death following CRC diagnosis is not impacted by a diagnosis of IBD in recent years. There is a very high proportion of post colonoscopy CRC among IBD-CRC, which has not changed over the years and needs detailed root-cause analysis and interventions. ApproxiSeveral epidemiologic studies have reported worse IBD-CRC survival rates than for sCRCs but have not controlled for colonic cancer site –8 and onSurveillance with regular colonoscopies has been the cornerstone of the strategies to prevent CRC morbidity and mortality among those with IBD. Guidelines recommend colonoscopy at 3–5 year (or shorter) intervals for most individuals with longstanding IBD .Much of the data on IBD-CRC predates the introduction of highly effective biological therapy for IBD and advances in diagnostic and therapeutic tests and strategies. Therefore, in this report, we aimed to assess if the characteristics of IBD-CRC, survival after IBD-CRC diagnosis, and use of colonoscopy pre-IBD-CRC diagnosis have changed over time compared to matched controls without IBD across the last two decades.Manitoba is a central Canadian province with a relatively stable population of approximately 1.3 million . ManitobUsing Manitoba’s population-based Manitoba Cancer Registry (MCR), individuals diagnosed with CRC between 1956 and 2018 were identified in the current study. The MCR records the stage at diagnosis for all cancers 2004 (available to 2017 for the current study). The MCR has been consistently shown to be of very high quality including high levels of completeness and histological verification . The UMIIndividuals with and without IBD were identified from the UMIBDED and those with CRC from the MCR. An individual with IBD was identified as a thiopurine user or 5ASA user if they had at least 2 dispensations of the respective medications and anti-TNF user if dispensed one prescription over the time period of follow-up included in the analysis. Only outpatient medication dispensations were included in this study as in-hospital pharmacy data are not accessible in the MH data.The Socioeconomic Factor Index (SEFI) was used to assess socioeconomic status. SEFI utilizes neighbourhood level social determinants of health such as unemployment rate and age dependency ratio . The SEFComorbidity burden was determined from ambulatory care and hospital admission diagnoses in 3–15 months prior to index CRC using the Charlson Comorbidity Index (CCI) score.th edition (AJCC6) classification system was used for cancer staging [The American Joint Committee on Cancer 6 staging . The datThe baseline characteristics of persons diagnosed with CRC were compared using chi square and Fisher’s exact tests. Continuous variables (Age and SEFI) were analysed using Wilcoxon and Kruskal Wallis non-parametric rank tests. Multivariable logistic analysis was performed including factors significant at p≤0.10 in univariable analysis to determine differences between IBD-CRC and sCRC. Exposure to colonoscopy in the 5 years to 6 months before CRC diagnosis was determined for those with and without IBD. We compared characteristics of those who had colonoscopy before IBD-CRC versus those who did not.Survival after CRC diagnosis was compared between persons with IBD-CRC and sCRC using proportional hazard regression models; covariates included age, sex, SEFI, site of CRC, year of CRC diagnosis and stage of CRC. Death from any cause was considered the endpoint. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated. Similarly, predictors of survival after IBD-CRC diagnosis were assessed.A nested case control analysis was performed to determine the association between CRC occurrence and colonoscopy 5 years to 6 months prior to CRC diagnosis. Individuals with IBD-CRC were matched (1:4) to individuals with IBD without CRC on the index date. Risk set sampling was used. Index date for this analysis was defined by the date of IBD-CRC diagnosis. Matching was based on age, sex, subtype of IBD (CD versus UC) and duration of IBD prior to CRC diagnosis. Conditional logistic regression analysis included covariates for SEFI, health care utilization, medication exposure, and colonoscopy exposure. Odds ratios (ORs) and 95% CIs were calculated. Because of the incidence density sampling, these ORs are unbiased estimates of incidence risk ratios.Data were analysed in three time periods, each containing approximately one third of the IBD-CRCs: 1984–2002, 2003–2011 and 2012–2018. The data on stage of CRC were only available for the years 2004–2017. For analyses including previous colonoscopy history, CRCs diagnosed in the years 1989–2018 were included, to be able to evaluate colonoscopy in the 5 years pre-IBD-CRC.In primary analysis, we used preceding 5 years to 6 months to define IBD-CRC as surveillance at 5-year intervals is recommended for some individuals with IBD. In a sensitivity analysis, we repeated the analysis for colonoscopy exposure 3 years to 6 months prior to IBD-CRC diagnosis.Data management and analyses were completed using SAS version 9.4 . This study was approved by the University of Manitoba’s Health Research Ethics Board and MH’s Health Information and Privacy Committee. To protect patient confidentiality, the linkage in this study was performed, via scrambled PHINs using anonymous versions of the datasets. The ethics committee waived the need for consent from study subjects.In total, 1,262 Manitobans diagnosed with CRC were included in the study, of whom 212 (16.8%) had IBD-CRC  and the rest sCRC. 77 of the IBD-CRC occurred in individuals diagnosed with IBD prior to 1987  and had median duration of IBD at CRC diagnosis of more than 12 years (IQR 7–22). 135 IBD-CRC occurred among individuals diagnosed with IBD from 1987 and a median duration of IBD of 12 years (IQR 4–18 years) at CRC diagnosis. The median age at CRC diagnosis was approximately a decade younger among cases with IBD-CRC when compared to sCRC . For IBD among CRC 50–69 versus >70, OR was 1.79, 95% CI: 1.19–2.69. Those with distal CRC were less likely to be IBD-CRC than those with proximal CRCs .When comparing CRC cases among persons diagnosed with CD and UC, persons with UC- CRC were more likely to be male . Persons with UC-CRC and CD-CRC were equally as likely to have seen a gastroenterologist in the 5 years to 6 months prior to CRC diagnosis . UC-CRC versus CD-CRC did not differ in the median age of IBD-CRC diagnosis, colonic CRC site, or histology. There were no differences in exposure to thiopurines and anti-TNF therapies between persons with CD-CRC or UC-CRC. There was a higher proportion of 5ASA use among persons with UC-CRC. In a Cox regression model with 5ASA exposure a time dependent variable (exposure: 2 years after a prescription dispensation), and model co-variates age, sex, IBD subtype (UC vs. CD), there was no protective effect of 5ASA use on CRC risk .Longer disease duration was associated with a lower proportion of colonoscopy and gastroenterology visits in the 5 years-6 months before CRC-IBD diagnosis . The proBecause stage of disease is an important predictor of survival, analysis was restricted to the CRCs diagnosed in 2004 to 2017, for which staging was available. Overall, IBD was associated with increased mortality in the multivariable analysis with co-variates sex, age, colonic CRC site, year of CRC diagnosis, grade, histology and stage at CRC diagnosis . In stratified analysis for CRC diagnosed 2004–11, IBD was associated with increased mortality  but not among CRC diagnosed in 2012–2017 . More specifically, one-  and three-year  survival rates did not differ between those diagnosed with and without IBD among individuals diagnosed with CRC in 2012–2017.In the multivariable analysis limited to IBD-CRC, individuals with shorter duration IBD prior to IBD-CRC diagnosis had better survival after CRC diagnosis . UC vs. CD diagnosis, age, sex, anti-TNF use, thiopurine use, 5-ASA use and being seen by a gastroenterologist in the 5 years to 6 months prior to CRC diagnosis did not impact survival among individuals with IBD-CRC. There was no effect of colonoscopy exposure in the 6 months to 5 years prior to IBD-CRC on survival after CRC diagnosis . Among those with UC-CRC, diagnosis of UC in hospital (marker of disease severity) did not impact survival after IBD-CRC diagnosis.In the 5 years to 6 months prior to CRC diagnosis (1989–2018), 51% of individuals with IBD-CRC underwent a colonoscopy versus 9% of sCRCs . Exposure to colonoscopy in the 5 years to 6 months prior to IBD-CRC diagnosis was similar for those diagnosed with CRC in the latest two time periods  The exposure to colonoscopy pre IBD-CRC diagnosis decreased slightly over time among those with long-standing IBD (> 15 years IBD duration) . Stage aExposure to colonoscopy in a 5-year time period for all individuals with longstanding IBD  . Individuals with IBD-CRC had more frequent colonoscopies in this time frame  than individuals with IBD without CRC  (p = 0.028). Eighty five percent of 5 years to 6 months pre index date colonoscopies for IBD-CRC included a biopsy as did 84% of colonoscopies for IBD without CRC (p = 0.87).About one-third of individuals underwent colonoscopy in the 6–36 months prior to IBD-CRC . For those diagnosed with IBD-CRC between 2003–2018, seeing a gastroenterologist was associated, with undergoing a colonoscopy prior to IBD-CRC diagnosis . Of the In this population-based study, a diagnosis of IBD was not associated with an increased risk of death after CRC diagnosis in the 2012–2017 era, and 51% of individuals diagnosed with IBD-CRC had post colonoscopy CRC (PCCRC), defined as CRC diagnosed within 5 years of a colonoscopy (and one-third within 3 years). Although persons with IBD-CRC, who saw a gastroenterologist before their CRC diagnosis were almost 5 times more likely to have a colonoscopy than those who did not see a gastroenterologist, exposure to colonoscopy pre- IBD-CRC did not confer a survival advantage after CRC diagnosis. Persons with IBD-CRC were younger and with more proximal CRC. We found a large proportion of individuals with longstanding IBD (> 8 years) did not have a colonoscopy in a 5-year time interval.Previously, individuals with IBD-CRC were reported to have lower odds of survival following CRC diagnosis when compared to the general population . In our PCCRC has been estimated to account for 3.7% of CRCs diagnosed in the general population . In compIndividuals with IBD undergo colonoscopy at a higher frequency than the general population and this has been suggested to be another possible explanation for the high percentage of PCCRCs in IBD-CRC . TroelseThe results of this study should be considered in the context of strengths and weakness. This is a population-based study evaluating practices, outcomes and time trends over a long time period. Our data are therefore not limited by selection bias. However, we did not have access to clinical charts, IBD phenotype or disease activity. The study was limited in its ability to report on disease characteristics such as duration of disease. Indications for colonoscopy could not be determined from the administrative health care data. Data on colonoscopy surveillance should be considered in the context of an entire cohort of IBD, without stratification for intestinal extent of IBD or indications of colonoscopy. Lastly, colonoscopy quality indicators could not be accounted for thus, the cause for PCCRC could not be determined.In conclusion, this study suggests short term survival after IBD-CRC diagnosis has improved recently. Longer follow up of this cohort will be required to determine if long term survival is also improved. Previous studies findings that CRC is increased in persons with IBD compared to matched controls and high risk of PCCRC among IBD-CRC further suggests that we must be vigilant and careful with surveying patients with IBD involving the colon for CRC. Importantly, since a large proportion of individuals with IBD-CRC had a colonoscopy within the preceding 6 months to 5 years of CRC, measures need to be developed to decrease these post colonoscopy IBD-CRCs.S1 Fig(DOCX)Click here for additional data file.S2 Fig(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Decreased light transmittance through the ocular lens, termed cataract, is a leading cause of low vision and blindness worldwide. Cataract causes significantly decreased quality of life, particularly in the elderly. Environmental risk factors, including aging, UV exposure, diabetes, smoking and some prescription drugs, are all contributors to cataract formation. In particular, drug-induced cataract represents a poorly-addressed source of cataract. To better understand the potential impact of prescription drugs on cataract, we analyzed publicly-available drug prescriptions data from the Australian Pharmaceutical Benefits Scheme. The data was analyzed for the 5-year period from July 2014 to June 2019. Analyses included the number of prescriptions for each drug, as well as the associated government and total prescription costs. The drugs chosen for analysis belonged to any of four broad categories—those with known, probable, possible or uncertain association with cataract in patients. The analyses revealed high prescription rates and costs for drugs in the Known category  and Possible category . Collectively, these data provide valuable insights into specific prescription drugs that likely contribute to the increasing annual burden of new cataract cases. These data highlight the need—as well as new, stem cell-based opportunities—to elucidate molecular mechanisms of drug-induced cataract formation. Cataracts disrupt light transmission through the lens of the eye. Excluding uncorrected refractive errors, cataracts are the leading cause of blindness and low vision worldwide—with over 65 million (M) patients affected in 2015  subsidizes the cost of prescription medicines approved for inclusion in the scheme. Among the PBS-listed medicines are drugs known or suspected to increase the risk of cataract. To investigate the number of prescriptions and associated costs for these drugs in Australia, we examined publicly available, PBS drug prescriptions data for the 5-year period from July 2014 to June 2019.Of the 31 drugs known to increase the risk of cataract , analysiMost notable among the Known category drugs prescribed over the 5 years were 11 steroids, of which 8 were in the top 10 most prescribed Known drugs . On aver).Over the 5-year period, 8 Known category drugs showed increasing annual prescriptions (5 steroids) and 9 showed increasing annual costs . The totOverall, these data indicate that numerous Known cataract-inducing drugs are being increasingly used. At a combined average annual cost of >$212 M per year, of which the direct government cost is > $102 M, it is clear a large investment is being made to treat patients using drugs known to increase the rate of cataract formation.Of the 9 drugs classified as having a probable association with cataract formation , only twOf the 23 drugs having a possible association with increased risk of cataract , 14 wereOf the 14 drugs in the Possible Category, 4  increased in annual prescriptions, government cost and total cost, including 4 of the top 5 drugs . The othThe other drugs having a Possible association with cataracts were the sulfonylureas  typicallOf the 15 drugs in the Uncertain category , the PBSThe prescribing rates of statins were mixed, with some trending up and others trending down over the 5 years . StatinsThe analysis of PBS data presented here shows tens-of- millions of prescriptions are filled every year in Australia for drugs known to or suspected of inducing cataract. The most prescribed and costly of these drugs are glucocorticoids, psychotropic drugs, and statins.Glucocorticoids—a class of drug known to cause posterior subcapsular cataract, particularly in people above the age of 40 —are presAs discussed below, minimizing drug-induced cataract could help offset the burden of cataract in Australia and elsewhere. The large number and cost of cataract surgeries likely arising from prescription steroids provides a strong argument for better understanding the molecular mechanisms of steroid-induced cataract. Application of such molecular knowledge could lead to early identification of at-risk patients, and potentially to development of alternative treatment strategies. For example, folate is recommended as a co-therapy with methotrexate prescribed for rheumatoid arthritis, to mitigate risks associated with methotrexate-induced folate deficiency .Clinically, the cataracts caused by glucocorticoid steroids are centrally-located, posterior subscapular cataracts with vacuoles , 10—suggPrimary human LECs transfected with firefly luciferase (controlled by glucocorticoid response elements) showed increased luciferase activity when exposed to dexamethasone —demonstrAnalysis of primary human LECs from patients with steroid-induced cataract showed a small increase in mRNA expression and protein activity for the matrix metalloproteinases, MMP2 and MMP-9 . Additioin vitro studies involving human LECs or lens cell lines were able to assess the effects of dexamethasone on critical lens functional properties of transparency or focusing.Overall, these studies provide initial insights into steroid-induced effects in human lens cells. However, their clinical relevance remains unclear due to differences  in behavior of immortalized lens cells compared to normal primary human LECs, and also the short timeframes being analyzed . Notably, none of these In Australia, one in five people experienced a mental disorder in a 12-month period , with maP < 0.001) and fluvoxamine  (p = 0.042) (p = 0.043) and sertraline ; sertraline  and fluvoxamine   , 20; flu= 0.042) , fluvoxa= 0.012) . A recen= 0.012) .These studies also showed many working-age patients  who have taken these psychotropic drugs have required cataract surgery, with direct implications for labor force productivity (discussed below) as well as direct medical costs. In some studies, the average time to cataract diagnosis while on SSRI (Selective Serotonin Reuptake Inhibitor) therapy was relatively short, ∼656 days . The larvia injection or eyedrops led to rapid development of dense cataracts thought to be related to reduced aqueous   could lead to elevated levels of serotonin, as detected in the aqueous humor of patients having undergone cataract surgery . In rats aqueous . These fd 5-HT7)  and expod 5-HT7) . A more Statins are prescribed to reduce blood cholesterol levels in order to reduce the risk of cardiovascular disease. Statins are effective inhibitors of 3-hydroxy-3-methyl-glutaryl-CoA reductase, a key enzyme in cholesterol biosynthesis. Statins can also increase expression of low density lipoprotein (LDL) receptors, enabling liver cells to capture cholesterol-containing LDL particles from the blood . The PBSWorldwide, cataracts are a large and increasing cause of blindness. The number of people with low vision or blindness due to cataracts increased from 50.5 M in 1990 to 65.2 M in 2015 . Direct in vitro, with lens transparency and light-focusing as functional end-points. This includes new opportunities to elucidate the molecular mechanisms through which prescription drugs cause cataracts. Such new knowledge could provide opportunities to decrease the annual global burden of cataract through improved identification of at-risk patients, prescription of co-therapies, or identification of candidate anti-cataract drugs. Such studies would address the large, unmet need for a reduction in the amount of drug-induced cataract that currently occurs worldwide. Use of human stem cell-derived micro-lenses could also provide a functional human lens system to reduce reliance on animal-based lens models for investigating molecular mechanisms of cataract formation  and PBS and RPBS Section 85 Date of Supply Data.MO’C: conceptualization, resources, project administration, and funding acquisition. MO’C and KM: methodology and supervision. JC and MO’C: validation and visualization. JC: formal analysis, investigation, and writing—original draft preparation. JC, MO’C, and KM: writing—review and editing. All authors have read and agreed to the published version of the manuscript.


N = 102; aged 13 to 17 years) were enrolled in the intervention (n = 42) and waitlist control (n = 60) conditions. Feasibility and acceptability were examined via attendance, and by qualitative interviews with a subset of students (n = 15), teachers (n = 2), and caregivers (n = 3). Preliminary efficacy was examined on primary outcome (emotion regulation) and secondary outcomes , which were measured at baseline and post-intervention (four weeks). Results: Delivering the intervention was feasible and acceptable, as demonstrated by low dropout (8%) and high program attendance (6.7 of 8 sessions). Qualitative data suggested high uptake of anger regulation skills, but lower uptake of mindfulness skills. Despite this, there were no significant differences by condition on primary or secondary outcomes at four-week follow-up. Students provided suggestions for improvement of the program. Conclusion: Further research on longitudinal outcome measurement, use of alternatives to retrospective self-report data, and rigorous development of culturally grounded models of emotion regulation is necessary to explore the utility of school-based emotion regulation interventions in Nepal and other LMICs.Background: Child and adolescent mental health problems are major contributors to the global burden of disease in low- and middle-income country (LMIC) settings. To advance the evidence base for adolescent mental health interventions in LMICs, we evaluated the feasibility and acceptability of a school-based emotion regulation prevention intervention  for adolescents who had a recent exposure to a humanitarian disaster. Methods: A mixed-method, non-randomized controlled trial was conducted with Nepali secondary school students in one heavily affected post-earthquake district. Students ( Child and adolescent mental health problems are major contributors to the global burden of disease . Mental Though factors contributing to mental health symptomatology among youth are heterogeneous, exposure to environmental and political trauma has emerged remains a consistent risk factor underlying the development of mental health and psychosocial problems . Prior sSchool settings provide a unique opportunity for addressing the mental health needs of conflict-affected youth. Schools are found in abundance throughout both the urban and rural landscape in LMICs, with overall rates of attendance dramatically improving since 2000 )man, the location of affect, memory, and uniqueness) and brain-mind . According to the model, external or internal events are thought to trigger emotional heaviness  in the man. Heart-mind problems result in socially inappropriate behaviors, which are then socially invalidated. This feedback loop, when coupled with an early predisposition  for emotional sensitivity and reactivity, results in a transacting model of pervasive dysregulation. If left untreated, more severe externalizing psychopathology  are theorized to result.This theoretical model synthesizes data on processes generating and maintaining emotion dysregulation developed in HIC  with NepThe resulting intervention, Regulating Emotions through Adapted Dialectical Behavior Skills for Youth , is a manualized, emotion-focused skills training program designed to promote positive mental health and support resilient responding in trauma-exposed adolescents. (See (dimaag), with associated images. The right side represents the heart-mind (man) division of self. The overlapping portion in the diagram signifies wise mind (buddhi mani soch). The handout on the right is an adaptation of DBT Observing & Describing Emotions (Shame). The text above the roots signifies emotion components visible to others, while that below the roots signifies private emotion components.The handout on the left is an adaptation of DBT Wise Mind. The left portion of the handout refers to the brain-mind Our primary research question concerned the feasibility, acceptability, and preliminary efficacy of READY-Nepal delivered in classroom settings. We aimed to examine if secondary school students self-selected into the intervention, the number of sessions attended by students, and that the measures were able to be completed. Additionally, we preliminary compared changes on a broad range of outcome measures relative to a wait-list control condition. Based on prior initial findings of gender-based differences in group interventions in Nepal and other LMIC ,30,31 ouAll portions of the study were conducted in collaboration with Transcultural Psychosocial Organization (TPO)-Nepal, a mental health research-oriented organization based in Kathmandu. The study received approval by the Nepal Health Research Council and Duke University’s Institutional Review Board (Pro#00071881).Nepal has a population of approximately 30 million , of whicThe specific study was conducted in Sankhu, a small population center in central Nepal that comprises approximately 2400 people . On accoA mixed-method, gender-stratified, non-randomized controlled design was conducted targeting Nepali secondary school students. Classrooms were not randomly assigned to conditions due to uneven school requirements. Classrooms with limited time available to participate in the intervention were assigned to the waitlist control condition, while those with availability were assigned to the intervention condition. In order to reduce the potential for contamination effects among students , participant groups were defined to match the school’s existing classroom designations, further subdivided only by gender. Each resulting group was then assigned as a whole to either experimental or control conditions. Quantitative outcome measures were taken on two occasions: one-week pre-intervention and four weeks post-intervention.Quantitative outcome measures were used to evaluate changes on a range of indicators, ranging from emotional and psychological difficulties, positive aspects of well-being, and mental health symptomatology. All quantitative data was collected pre-intervention and 4-week follow-up via a self-administered, tablet-based battery. This method was preferred over typical verbal administration due to the literacy level of participants, in addition to the need to maximize potential reductions in available time for participating students.Emotion Regulation. Changes in emotion regulation were assessed using an adapted version of the Difficulties in Emotion Regulation Scale . The DEe : The DBT-WCCL is an adaptation of the Revised Ways of Coping Checklist  that in . The BAry . The 17. The seFunctional Impairment. Changes in two-week adolescent functional impairment were measured using the Nepali version of the Child Functioning Impairment Scale . The CFResilience. Changes in two-week adolescent resilience were measured using items adapted from the Wagnild & Young Resilience Scale [ce Scale . This adce Scale . Items aSuicidal Ideation. Changes in past-two-week suicidal ideation, was assessed via a 4-item scale with “yes” and “no” response type options. Students with answers of “yes” were assessed for risk by a study team member . Those assessed as having high risk  were referred to an on-site counselor at TPO-Nepal for risk management.n = 10), teachers (n = 2), and caregivers of participating students (n = 3) to explore perceived feasibility and acceptability of the intervention. The qualitative sample was recruited via purposive sampling with stratification by gender . Recruitment was based on availability and study interest.Three semi-structured interview guides were separately developed and completed at four-week follow-up with students in both conditions  and pilot tested with clinicians at TPO-Nepal, with minor revisions made for clarity and flow.Three local research assistants and two US masters-level researchers who were not involved in service delivery were selected and received one week of quantitative and qualitative research training. It was not possible to blind assessors to treatment status, as they were required to visit the site to conduct both quantitative assessments and qualitative interviews.t-tests were used to compare completers vs. dropouts in addition to intervention vs. control participants. Baseline differences in general characteristics and outcome measures were then assessed via Wilcoxon rank sum test for continuous measures or Chi Square tests for categorical measures. Correlations between baseline outcome variables are presented in All statistical analyses were conducted using SPSS Version 28.0 . First, Semi-structured interviews were used to complement quantitative data by providing preliminary data relevant to the intervention’s broader feasibility, acceptability, and dissemination potential. Interviews were transcribed, translated, and reviewed for accuracy. QSR NVivo software version 11.0 was utilized for data management and analysis. The analytic approach was informed by thematic analysis. All of the English transcripts were carefully reviewed by two members of the research team, with both identifying patterns to inform codebook development through this collaborative review. When the codebook was finalized, 20% of the transcripts were double coded with discrepancies discussed until 90% inter-coder agreement was reached. Themes emerged as comparisons within and across individuals were made, and representative quotations for each of the identified themes were selectedN = 102) were adolescents aged 13 to 17 years, attending one earthquake-affected secondary school in Sankhu identified through key informants at TPO-Nepal. Allocation to study conditions (See n = 6) was identified through collaboration with school administrators through use of an official class registry. Classrooms were eligible for participation if students were between the ages of 13 and 17. Next, whole classrooms were non-randomly assigned to either intervention or control conditions. Classrooms were eligible for enrollment in the intervention condition if they (1) had a free period during the allocated intervention time; (2) had a relatively equal proportion of males and females; and (3) students were not preparing for a national secondary school examination at the time of intervention delivery. Classrooms enrolled in the intervention condition (n = 2) were then segregated by gender, leading to the formation of four groups (n = 40 participants). All other classrooms  were assigned to the wait-list condition, who received the intervention the subsequent year.Study participants (ions See  followedn = 28) reported current  suicidal ideation. At baseline, 14.6% of participants (n = 14) reported any lifetime suicidal behavior .Demographic and clinical characteristics and suicidal behaviors are summarized in n = 10) included six females (60%) and four males (40%) distributed between grade 7 (50%), grade 8 (10%), and grade 9 (40%). The mean age was 14 years. A majority were Newaris (60%), one was high-caste Brahmin (10%), one was low-caste Dalit (10%), and two self-identified as other (20%). Teachers (n = 2) were 50% female. Caregivers (n = 3) were 100% female and included two biological mothers and one grandmother.The qualitative sub-sample of students (M = 6.7), with females attending a higher mean number of sessions (7.1) relative to males (6.3).Average dropout (defined as missing more than 50% of sessions) was low (8%), with rates for females (6%) lower than males (9%). Overall attendance in the 8-session READY-Nepal program was high , such that impairment significantly decreased over time across both conditions. Additionally, there was a significant time*gender interaction for Anxiety (p = 0.011), with females reporting lower anxiety symptoms relative to males across both conditions. No other significant differences were found. Hierarchical regressions examining gender as a moderator found no significant gender*condition interaction effects . See for The first column represents full-sample changes by condition, while the second column segregates pre- and post-intervention differences by gender. Blue and red lines represent the intervention and control conditions, respectively.n = 10 from n = 13) and remained unchanged in the control condition. For females, suicidal ideation decreased in intervention condition (n = 7 from n = 9) and increased in the control condition (n = 10 from n = 7). For males, suicidal ideation decreased in both the intervention (n = 3 from n = 4) and control (n = 5 from n = 8) conditions.Due to the small base rate of suicidal behaviors by condition, statistical modeling changes in suicidal behavior was not appropriate. n = 7; 87.5%) of adolescents in the READY-Nepal condition preferred a group format with separation by gender, highlighting acceptability of these two program components. All females (n = 5) and males (n = 3) highlighted specific utility of opposite action to anger. Three indicated that mindfulness skills  were difficult to grasp conceptually, and that skills taught through the curriculum would be better-suited for older youth populations (age 18–21) due to their relatively higher level of abstraction. Participating students also recommended a number of improvements, including decreased session length (from 1 h to 45-min to accommodate classroom schedules) and a greater total session count , inclusion of a reward system to facilitate engagement, inclusion of family members into the intervention, and an increased focus on social interaction skills.n = 2), one female shared that females participating in the intervention had shared skills with her , and this was less common for males. Teachers (n = 2) expressed a range of opinions on the intervention, with one recommending greater system-level coordination between facilitators, teachers and school administration to support teacher’s ability to reinforce and generalize skills use in the classroom setting. Caregivers (n = 3) of students participating in the intervention suggested minimal sharing of content learned at home, and mixed improvements.For students in the control condition  and high mean session attendance (6.7), with retention rates higher for females relative to males. The low dropout rate is parallel with examinations of school-based mindfulness interventions delivered in HIC, and lower than existing trials of school-based mindfulness interventions in Asia  and DBTQualitative findings complemented dropout and attendance data, by indicated feasibility and acceptability of specific program content. A majority of adolescents in the READY-Nepal condition shared a preference for group-based  sessions to promote social interaction and connection. A majority also preferred group separation by gender, and believed that this allowed for discussion of gender-specific topics and promoted within-gender connectedness. All adolescents recalled and highlighted the utility of opposite action to anger, suggesting that this led to a calm heart-mind and facilitating healthy social relationships.Despite promising feasibility and acceptability, we found no quantitative improvements in either primary (emotion regulation) or secondary outcome variables  at four-week follow-up between study arms. These findings exist against a backdrop of mixed findings on school-based emotion regulation interventions. In one recent meta-analysis of emotion regulation psychosocial interventions for adolescents in community-based and war-affected settings ), there n = 4) reporting mixed or null findings. Further exploratory analyses that aim to identify sub-groups or sub-populations of students that benefitted from the READY-Nepal intervention is thus warranted, in order to identify individuals that may derive maximal benefit from the intervention. It is of note that, given the higher proportion of mental health symptomatology in our sample relative to other similar-age samples [Given these prior findings as well as our own, one explanation for the lack of significant quantitative findings is the presence of floor effects, which are common in universally delivered programs given the relative health of the sample compared to a clinical group. Of existing empirically supported, school-based interventions in LMICs, half have utilized targeted screening to only enroll select students . In con samples ,52, thesOur measurement selection and timing of delivery may also influence quantitative findings. The original DERS was developed to measure dispositional tendencies  and mayAn additional competing explanation for quantitative findings is that DBT skills require higher-level abstraction and metacognitive abilities that are developmentally less prevalent among youth (age 12–17) who comprised our sample. Mindfulness skills, which comprise the foundation of DBT skills training curricula, are one example of a metacognitive series of behaviors requiring the individual to not only recognize their own cognitive thinking patterns but also decenter from them. Our qualitative findings showed low uptake of mindfulness skills by students, which has also been show in prior studies with non-Western populations . QualitaQuestions regarding optimal dosage of school-based interventions in LMIC populations remain to be explored. In one systematic review of school-based mental health programs in LMICs , the ave(n = 6) of trials in LMICs, and an even larger number in HICs, have utilized a health promoting schools model by which socio-emotional learning is embedded into the school’s existing health education curriculum and is taught at the whole-school level [A number ol level . Althougol level , family A number of strengths accompanied this study. In addition, to the authors’ knowledge, ours is among the first study to examine the psychological effects of an emotion regulation intervention for adolescents in Asia. The cultural adaptation, simplification and manualization of didactic content for lay providers also enhance its dissemination and implementation potential in other resource-strained contexts in Asian settings. Its scalable nature is one key component broader global mental health agenda emphasizing delivery of culturally sensitive, effective, and appropriate care for vulnerable populations.Limitations also exist. One is the use of a non-randomized control group, which has the potential to result in lack of baseline equivalence between the intervention and control conditions on a number of variables. Use of a non-randomized design may also result in selection bias and influence of non-random variables on study enrollment and, ultimately, study findings. Our study design study was also not powered for inference testing. The two-measurement, pre-post design also precluded any assessment of the durability of effects beyond four-weeks post-intervention. Our use of culturally modified, comparatively brief scales  further compromises the strength of any potential inferences and limits our ability to compare findings with those from other trials in LMICs. Future testing with more rigorous experimental control and improved internal validity is therefore warranted to corroborate (or nullify) current findings. Further testing  is also merited, to examine profiles of individuals who benefitted from the intervention.Regulating Emotions through Adapted Dialectical Behavior Skills for Youth  is a brief (8-session) intervention targeting universal prevention of mental health symptoms among disaster-exposed youth in Nepal. In a mixed-method, gender-stratified, non-randomized controlled trial of READY-Nepal, we found that the program was feasible to implement and acceptable among school-going adolescents. Qualitative results indicated student retention of anger management skills and low utilization of mindfulness skills. Despite promising feasibility and acceptability, we found no significant quantitative improvements in either primary or secondary outcomes between conditions. Future research should utilize longitudinal outcome measurement, alternatives to self-report, and rigorously develop culturally grounded models of emotion regulation to explore the utility of school-based emotion regulation interventions in Nepal and other LMICs.


To assess the association between newborn birth weight and the presence of intra-amniotic infection, presence of sterile intra-amniotic inflammation, and absence of intra-amniotic inflammation in pregnancies with preterm labor with intact membranes.A total of 69 pregnancies with preterm labor with intact membranes between gestational ages 22 + 0 and 34 + 6 weeks who delivered within seven days of admission were included in this retrospective cohort study. Transabdominal amniocentesis to determine the presence of microorganisms and/or their nucleic acids in amniotic fluid (through culturing and molecular biology methods) and intra-amniotic inflammation (according to amniotic fluid interleukin-6 concentrations) were performed as part of standard clinical management. The participants were further divided into three subgroups: intra-amniotic infection , sterile intra-amniotic inflammation , and without intra-amniotic inflammation. Birth weights of newborns were expressed as percentiles derived from the INTERGROWTH-21st standards for (i) estimated fetal weight and (ii) newborn birth weight.p = 0.06). Differences among the subgroups were identified in the birth weight rates, expressed as percentiles derived from the standard for estimated fetal weight, which were less than the 10th percentile  and 25th percentile . No differences among the subgroups were observed when percentiles of birth weight were derived from the birth weight standard.No difference in birth weights, expressed as percentiles derived from the standard for estimated fetal weight, was found among the women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation (with infection, median 29; with sterile inflammation, median 54; without inflammation, median 53; The presence of intra-amniotic inflammatory complications in pregnancies with preterm labor with intact membranes prior to the gestational age of 35 weeks was associated with a higher rate of newborns with birth weight less than the 10th and 25th percentile, when percentiles of birth weight were derived from the standard for estimated fetal weight. Preterm labor with intact membranes (PTL), a clinical phenotype of spontaneous preterm delivery, accounts for approximately one-third of all preterm deliveries –3. This Ureaplasma spp. in the cervix e cervix .Escherichia coli) decreased birth weight in a rat animal model  aal model ; (iv) elal model ; (v) sertriction ; and  was conducted with the following goals: (i) to assess the difference in birth weight, expressed as percentiles derived from standards for estimated fetal weight and newborn birth weight, between the subgroups of those with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation; and (ii) to compare the rates of birth weights that are less than the 1st, 3rd, 10th, and 25th percentiles among the subgroups with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation.This retrospective study included pregnant women admitted to the Department of Obstetrics and Gynecology of the University Hospital Hradec Kralove, Czech Republic, between March 2017 and November 2021, who met the following criteria: (i) age ≥18 years; (ii) singleton pregnancy; (iii) gestational age between 22 + 0 and 34 + 6 weeks; (iv) PTL with delivery within seven days of admission; and (v) underwent amniocentesis to assess microbial invasion of the amniotic cavity and intra-amniotic inflammation. The exclusion criteria were as follows: (i) pregnancy-related and other medical complications ; (ii) congenital or chromosomal fetal abnormalities; (iii) signs of fetal hypoxia at the time of admission; (iv) significant vaginal bleeding; and (v) preterm prelabor rupture of membranes.Gestational age was determined based on the first-trimester fetal biometry. PTL was defined as the presence of regular uterine contractions (at least two every 10 min) along with a cervical length <15 mm on transvaginal ultrasound or cervical length of 15–30 mm with a positive PartoSure test  . TransabStreptococcus agalactiae or did not have these results available received intravenous benzylpenicillin  during active labor.Women with PTL received an antenatal course of corticosteroids (betamethasone) and tocolytic therapy with either intravenous atosiban  or oral administration of nifedipine for 48 h. Women diagnosed with intra-amniotic inflammation received clarithromycin intravenously for seven days, unless delivery occurred earlier. Antibiotic treatment was eventually modified based on the results of microbial assessments of amniotic fluid. Women with PTL who were positive for the vaginal-rectal presence of The collection of clinical samples and information from women with PTL was approved by the Institutional Review Board Committee . Written informed consent was obtained from all women. All the women in the study were self-reported as Caucasians. Biological samples  from the women included in this study were used in our previous studies , 23.Ultrasonography-guided transabdominal amniocentesis was performed before administration of corticosteroids, antibiotics, or tocolytics. Details of amniotic fluid sampling have been previously described , 23.The concentration of interleukin (IL)-6 in amniotic fluid was assessed using an automated electrochemiluminescence immunoassay method with the immuno-analyzer Cobas e602  . The mea@C. trachomatis/Ureaplasma/M. hominis-FRT kit  was used to detect DNA from Ureaplasma species, M. hominis, and C. trachomatis in the amniotic fluid. The details of this specific PCR run in a single PCR tube have been previously described  and Statistical Package for Social Sciences (SPSS), version 28.0.0.0, for Windows .The demographic and clinical characteristics of the patients were compared using the non-parametric Kruskal-Wallis test for continuous variables and the chi-squared test for categorical variables, and the results are presented as median [interquartile range (IQR)] and number (%), respectively. The normality of the data was tested using the Anderson–Darling test. The percentiles of birth weight were not normally distributed; therefore, the non-parametric Jonckheere-Terpstra test was used for the analyses. The Cochran-Armitage test for trends was used to compare birth weight rates among subgroups. Spearman's partial correlation analysis was performed to adjust the results for a potential confounder (antibiotic administration). Differences were considered statistically significant at n = 17), ii) preeclampsia (n = 4), pregestational diabetes mellitus (n = 2), and gestational hypertension (n = 2). The remaining 69 women were included in the analysis.In total, 94 women with singleton pregnancies complicated by PTL who delivered within seven days of admission were eligible for the study. Twenty-five women were excluded for the following reasons: i) gestational diabetes mellitus (Ureaplasma spp. + Capnocytophaga ochracea + Fusobacterium nucleatum (n = 1), Lactobacillus spp. + Gardnerella vaginalis (n = 1), Ureaplasma spp. (n = 5), Streptococcus spp. (n = 1), Sneathia sanguinegens (n = 1), Lactococcus lactis (n = 1), Haemophilus influenzae (n = 1), Fusobacterium nucleatum (n = 1), Burkholderia cepacia (n = 1), and non-identifiable bacteria by sequencing (n = 2).Microbial invasion of the amniotic cavity and intra-amniotic inflammation were observed in 15 (22%) and 47 (68%) women, respectively. The microbial findings from the amniotic fluid were as follows: Intra-amniotic infection, sterile intra-amniotic inflammation, and absence of intra-amniotic inflammation were found in 15 (22%), 32 (46%), and 22 (32%) women, respectively. None of the women had microbial invasion of the amniotic cavity without intra-amniotic inflammation.The demographic and clinical characteristics of the study population with respect to the presence of intra-amniotic infection, presence of sterile intra-amniotic inflammation, and absence of intra-amniotic inflammation are shown in p = 0.06; p = 0.04 and 25th percentile: p = 0.01, p = 0.04; 25th percentile: p = 0.02).No differences were found among the subgroups of women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation in percentiles of newborn birth weight , 81% (26/32), and 100% (22/22) of newborns from pregnancies with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation, respectively.p = 0.98; No differences among the subgroup of women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation were identified in percentiles of newborn birth weight  no difference in percentiles of birth weight, derived from estimated fetal weight standard, was found among the subgroups of women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation; (ii) differences in the rates of birth weight that were less than the 10th and 25th percentiles, derived from the standard for estimated fetal weight, were identified among the subgroups of women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation; and (iii) no differences among the subgroups were revealed when percentiles were derived from the standard for birth weight.Escherichia coli) at 20 days of gestation (the term is 22 days) led to a 20% and 22% decrease in birth and placental weights, respectively  might have affected fetal growth when compared to the presence of weak intra-amniotic inflammation  or the absence of these conditions. We do not want to overemphasize this observation; however, this hypothesis is further supported by the trend in the rates of newborns with a birth weight less than the 10th and 25th percentiles among the subgroups, with this trend being the highest in those with intra-amniotic infection, lower in those with sterile intra-amniotic inflammation, and the lowest in the absence of inflammation. The difference among the subgroups was revealed only in the cutoff values of the 10th percentile, which is commonly used by clinicians to identify fetuses and newborns with a diagnosis of small for gestational age , and theectively . Intra-aectively –36. In aectively .Since intra-amniotic infection is considered a cause of cervical insufficiency with prolapsed fetal membranes or PTL rather than a consequence, it is likely that the fetal and placental exposure to this complication might be a long-lasting process compared to preterm prelabor rupture of membranes (PPROM), where this intra-amniotic complication is more likely a consequence. Collectively, the observations from this study are in line with those of our previous studies , 21. TheIn this study, aside from the INTERGROWTH-21st standard for estimated fetal weight, the standard for newborn birth weight was also used to derive percentiles for birth weight. When this standard was applied, no differences in percentiles among the subgroups in the rates of birth weight less than the 1st, 3rd, 10th, and 25th percentiles were found. A similar phenomenon was observed in our previous studies , 21. We Ureaplasma spp., Mycoplasma hominis, and Chlamydia trachomatis; and (iii) PCR for the 16S rRNA gene followed by sequencing. The employment of such an extensive approach offered us the opportunity to divide the subset of women with intra-amniotic inflammation into those with intra-amniotic infection and those with sterile intra-amniotic inflammation. Second, there is strong evidence that the latency interval between admission and delivery in pregnancy with PTL depends on the presence or absence of intra-amniotic inflammation  aerobic and anaerobic cultivation; (ii) specific PCR for ammation , 8, 12. ammation , 8, 12. ammation , 40 or oHowever, this study had some limitations. First, the small cohort of women with PTL used in this study was limited. The monocentric design of the study prevented us from using a larger sample size. Second, the population of women used in this study was homogeneous, involving only Caucasian participants. This potential shortcoming prevents the results of the study from generalizing to populations with broader ethnic and racial disparities. Finally, data regarding ultrasonographically estimated fetal weight obtained at the time of admission were not available. Therefore, we could not compare the percentiles of ultrasonographically estimated fetal weight at the time of admission, derived from the standard for estimated fetal weight, among the subgroups.In conclusion, in this retrospective cohort study conducted on pregnancies with preterm labor and intact membranes prior to the gestational age of 35 weeks, the presence of intra-amniotic inflammatory complications was associated with a higher rate of newborns with birth weight less than the 10th and 25th percentile, when percentiles of birth weight were derived from the standard for estimated fetal weight.