Vaccination behaviour is influenced by various determinants. Evidence indicates a higher COVID-19 vaccine hesitancy among university students due to their age and a lower risk of complications compared to the general population in Germany. However, little is known about other COVID-19-related determinants for the population of German university students. This study aimed to investigate determinants of vaccination behaviour among German university students.The cross-sectional COVID-19 German Student Well-being Study was conducted at five German universities at the end of 2021 via an online survey (n = 7.267). Multiple logistic regressions were calculated to examine associations of vaccination behaviour (not vaccinated vs. fully vaccinated) and attitudes towards vaccination , health literacy in a pandemic (CHL-P), and additional determinants.All 5Cs were associated with the vaccination status ‘fully vaccinated’, except for complacency. Regarding CHL-P, we found that students who felt that the current scientific knowledge about COVID-19 in terms of the policy decisions on pandemic measures was very complex had a higher odds for being vaccinated . Regarding additional determinants, the analysis revealed that students who had been previously infected had in all regressions a lower odds for being vaccinated compared to students with no previous infection.Due to the strong association of the attitudes towards vaccination and vaccination behaviour among university students, we recommend that the different components of the 5Cs should be considered in future COVID-19 vaccination campaigns in the university context.Attitudes towards vaccinations impact on vaccination behaviour among university students.Perceiving the current scientific knowledge on COVID-19 as very complex increased the odds for vaccination.


The increased demand for training of mechanical thrombectomy in ischemic stroke and development of new recanalization devices urges the creation of new simulation models both for training and device assessment. Clots properties have shown to play a role in procedural planning and thrombectomy device effectiveness. In this study, we analyzed the characteristics and applicability of completely synthetic, animal-free clots in the setting of an in-vitro model of mechanical thrombectomy for training and device assessment.Synthetic clots based on agarose (n = 12) and silicone (n = 11) were evaluated in an in-vitro neurointervention simulation of mechanical thrombectomy with clot extraction devices. Calcified clots of mixed nature were simulated with addition of 3D printed structures. 9 clots were excluded due to insufficient vessel occlusion and failure to integrate with clot extraction device. Synthetic thrombi were characterized and compared using a categorical score-system on vessel occlusion, elasticity, fragmentation, adherence and device integration.Both agarose-based and silicone-based clots demonstrated relevant flow arrest and a good integration with the clot extraction device. Silicone-based clots scored higher on adherence to the vessel wall and elasticity.Selected synthetic clots can successfully be implemented in an in-vitro training environment of mechanical thrombectomy. The clots’ different properties might serve to mimic fibrin-rich and red blood cell-rich human thrombi. Clinical evidence has shown in the past years the undeniable value of mechanical thrombectomy (MT) in the treatment of acute large vessel occlusion (LVO) . This leClot composition has been shown to play a role in the etiology and characterization of ischemic stroke in large vessel occlusions . This maOur hypothesis was that synthetic clots allow for sufficient vessel occlusion and device interaction in an experimental simulation model of mechanical thrombectomy when evaluated by experienced neurointerventionalists, and that different clot compositions may show different mechanical properties which may mimic characteristics found in human clots.Synthetically produced clots (n = 23) mainly composed of agarose  or silicone  were tested in a previously described neurovascular simulation model . DiffereSynthetic clot testing was performed in a neurovascular simulation environment (HANNES) , 8 integA standard short 8F sheath was placed in the right femoral artery of the experimental model. An 8F-FlowGate guiding catheter  was introduced into the internal carotid artery. Clots were directly administered into the common carotid artery of the experimental model via an additional, for this purpose constructed cervical arterial branch. The resulting clot position was evaluated with 10 ml of iodinated contrast medium  in a single angiographic run . Each clClots were qualitatively evaluated in the HANNES model by three neuroradiologists with an average of 5 years-experience in angiography. Evaluation was performed using an ordinal classification scale with a 5-point system (0 to 4) based on qualitative thrombi characteristics with five items: vessel occlusion, elasticity, fragmentation, adherence and device integration . This waAgarose-based thrombi were primarily soft and fragile, tendentially breaking before installation in the vascular model. Addition of MCI/MI showed to significantly reduce their breakability and helped producing compacter structures. Addition of other solid elements such as resins developed and printed in different shapes using 3D-printing techniques showed to be a feasible solution in the production of synthetic models mimicking the behavior of calcified clots of mixed nature. Fragmentation showed to be the main feature of agarose-based clots.Pure silicone clots presented as too stiff and failed to show the adherence expected form fibrin clots. Realistic slightly more malleable and more adherent clots could be achieved by adding different concentrations of MCI/MI. Added micro-glass beads (MGB) lead to a further increase in fragmentation and adhesion to vascular model walls. Material “stickiness” was effectively reduced through preservation of clot material in an oily substance. Silicone-based clots showed variable degrees of adherence and elasticity as well as reduced fragmentation.7 agarose-based clots and 7 silicone-based clots were included in the analysis. Both types of clots caused relevant flow arrest and demonstrated a good integration with the clot extraction device . A moderIn this experimental study, we developed and tested a novel concept of animal-free synthetic clots for training and research on mechanical thrombectomy, in an in-vitro setting, using a previously well-established neurovascular simulation model . Clots wBerndt et al. proposed a collection of embolus analogs based on human and pig’s blood for device evaluation and training . Other sPrevious studies have stated the importance of clot histological composition on its mechanical properties and secondarily, on the effectiveness of revascularization techniques in ischemic stroke . Clots cDevelopment of artificial thrombi with different properties is important for a realistic simulation of MT. In this study we describe artificial clots that potentially mimic the natural behaviors found in red, white, mixed or calcified clots. Red or RBC-rich clots present predominantly with a viscoelastic soft texture  and highWhite or fibrin-rich clots have been described as stiffer, presenting increased friction or adherence on the vessel wall . Aged thThe agarose-based clots presented in this study may mimic white, mostly aged clots, showing reduced elasticity and fairly high breakability. However, the expected adherence of such clot materials fails to be met. On the other hand, highly elastic silicone-based clots with variable degrees of breakability presented with high level of adherence. Nonetheless, in this study clot adherence did not affect the technical success of MT. Further developments on clot analogs composition are necessary to optimize artificially composed thrombi and to make them easily available to a higher number of neurovascular centers involved in the research and training of MT.The exploratory study design with qualitative data interpretation is typically subject to researcher confirmation bias, which may influence the results and make the data less replicable. The neurointerventionalists were not blinded to clot type upon their evaluation. Inter-observer differences could be overcome with further development of objective quantitative assessment methods in this in-vitro set up. Furthermore, an exact comparison between synthetic and human clots can only be achieved by comparing their mechanical properties.Selected synthetically composed clot analogs achieved sufficient vessel occlusion and integration with the clot extraction device in an in-vitro stroke thrombectomy model. The characteristic properties of agarose-based and silicone-based clots may be used to mimic different types of human thrombi. Synthetic clots could effectively be used for device testing, as well as for training of endovascular treatment of ischemic stroke.S1 Tabledevice integration) were classified as not suitable for an in-vitro experimental setting and thus excluded .Clots that failed to interact with the clot removal device (Score = 0 for the category (DOCX)Click here for additional data file.S1 Fig(a-d). Silicone-based clots mixed with 30% MCI/MI with  and without micro-glass beads : before  and after  mechanical sheer stress showing different breakability and elasticity degrees.(DOCX)Click here for additional data file.S2 Fig(a-c). Retrieved clots with stent retriever. Agarose-based clots mixed with 10% MCI/MI , with spiral (a) or barbed (c) supporting structures, and with 20% MCI/MI (b) were successfully retrieved with a clot extraction device .(DOCX)Click here for additional data file.


Two groups were made of chair-side PFC composites  with or without SFC-core . One group was made of laboratory PFC composite  with or without SFC-core. The last group was made of plain SFC composite polymerized with a hand-light curing unit only or further polymerized in a light-curing oven. Using a universal-testing device, crown restorations were statically loaded until they fractured, and failure modes were visually investigated. Analysis of variance (p = 0.05) was used to evaluate the data, followed by Tukey’s post hoc test. Bilayer structure crowns with SFC-core and surface PFC gave superior load-bearing capacity values compared to those made of monolayer PFC composites; however, significant differences (p < 0.05) were found in the chair-side composite groups. Additional polymerization has no impact on the load-bearing capacity values of SFC crowns. Using SFC as a core material with PFC veneering composite to strengthen anterior crown restorations proved to be a promising strategy for further testing.The aim of this study was to investigate the load-bearing capacity of anterior crowns made of different commercial particulate-filled composites (PFCs) and reinforced by a core of short-fiber composite (SFC) (bilayer structure). Four groups of composite crowns were fabricated for an upper central incisor ( Endodontically treated teeth (ETT) often require substantial build-up with varying post-core foundation materials to retain a complete crown restoration . In receDirect and indirect particulate-filled composites (PFCs) have been successfully used in the clinic for large anterior and posterior restorations ,5. NeverMany in vitro studies with different applications have looked at bilayer structure composite using SFC as the thick core layer and PFC as the top surface layer ,16,17. IAn experimental abutment (model) for a crown restoration of the upper first incisor was fabricated from Cobalt Chromium blank  using a CAD/CAM device . The abutment was next sintered according to the product instructions in a furnace . Except for 2 mm of the cervical area, the metal abutment was then implanted in a plastic tube with self-cured acrylic resin . Another dental CAD/CAM device was used to take a photo-impression of the abutment . An incisor crown restoration was created with a flat surface at the incisor edge in order to adapt to the loading cell during the fracture test.n = 20/group) according to the technique and material used . The light source was put in close proximity to the composite surface (1–2 mm). According to the manufacturers’ instructions, Gradia Plus restorations were additionally polymerized in a light-curing oven (Targis Power) for 15 min. The crowns were firmly fixed on the sandblasted and silanated  metal abutment by only resin without any cement. All crown restorations were polished and stored dry for 48 h at 37 °C before testing.For these groups, a transparent template matrix of an appropriately shaped crown  was employed to help standardized crown restorations. The composite pastes were packed into the space created between the index and the abutment (with or without SFC-core), then light curing was performed using a hand-light curing unit  for 40 s per segment  was used to apply a quasistatic load to the crown restorations at a speed of 1 mm/min. The acrylic block having the metal abutment and crown was firmly placed on the inclined metal base to offer a 45-degree angle between the loading tip (flat) and the palatal surface of the incisal edge B. SheetsScanning electron microscopy was used to qualitatively investigate representative fractured restorations. . All of the specimens were cleaned and then coated with a gold layer using a sputter coater in a vacuum evaporator  prior to observation. The analysis was initiated from the edge of the fractured crown specimen, from the upper PFC loading part to the inner surface and ending at the SFC-core.p < 0.05 significant level, followed by a Tukey HSD post hoc test.To assess the differences between the groups, the data were statistically analyzed with SPSS version 23  using analysis of variance (ANOVA) at the p < 0.05) impact on the load-bearing capability of tested crowns, p < 0.05) were found in direct composite groups. Additional polymerization has no impact on the load-bearing capacity values of plain SFC crowns (p > 0.05). For all crown restorations (monolayer or bilayer structured), a splitting fracture mode was found during the visual assessment  of fractured bilayer structured crowns revealed that the fracture crack path propagated radially from the loading surface  through PFC composite to the inner part at the SFC-core A. FigureThe current study compared the effects of two restorative techniques (monolayer structure or bilayer structure with SFC-core) for fabricating anterior crown restorations utilizing different direct/indirect composites.1/2. Hence, we hypothesized that a bilayer structure system would improve the load-bearing capacity of anterior composite crown restorations. Our results revealed enhancements in the load-bearing capacity of the restorations when SFC-core was applied in comparison with that of plain (monolayer structure) PFCs  used in this study ,14. To ore) PFCs . Accordire) PFCs , hence iA number of manufacturers have developed SFCs that claim to overcome the weakness of conventional PFC; however, comparative studies from the literature showed that commercial SFCs have different properties, structures, and reinforcing capacities ,23. BaseTo gain support from the SFC-core for the PFC, the SFC-core’s toughness must be greater than the PFC surface layer’s ,25. In lInterestingly, the load-bearing capacity of the reinforced laboratory PFC composite restorations (Gradia Plus) was lower than that of the reinforced chair-side composite restorations . The difAnother aspect that may lead to different load-bearing capacity values is the type of cementation and material used ; howeverCorrelation with the clinical fracture loads is complicated, as the die material  and its modulus of elasticity will significantly influence stresses within the crowns. This could be considered a major limitation of our study. A metal  model was used because it aids standardization of the crown abutment and the crown shape, allowing the effect of the material type to be the only variable factor.An oblique load (45° to the long axis of the tooth) was applied to the tested crowns, which seems to be the worst-case scenario in relation to the load-bearing capacity of anterior crowns . To mimiThe ultimate quasistatic force to fracture the crown  was determined in this study. Stress applied to dental restorations and teeth is low and cyclic, rather than being static or impact in nature; however, static load is a common approach for testing dental materials used for dental restorations to evaluate their mechanical stability for different applications prior to clinical trials ,31,32. SUsing SFC as core material with conventional PFC veneering composite to strengthen anterior crown restoration proved to be a promising strategy for further testing.


Superior mediastinal syndrome secondary to an anterior mediastinal mass can be seen in acute lymphoblastic leukaemia (ALL) of T-cell lineage. We report a 3-year-old child with B-cell ALL, who presented with the superior mediastinal syndrome. The CT scan chest showed a huge anterior mediastinal mass and the peripheral blood immunophenotyping showed B-cell ALL. High-risk remission induction chemotherapy was given and he achieved remission by the end of induction therapy, both in terms of medullary and extramedullary disease, and is on maintenance chemotherapy now. This is the first reported case of a paediatric B-cell ALL presenting with superior mediastinal syndrome secondary to an anterior mediastinal mass. B-cell acute lymphoblastic leukaemia (ALL), the most common paediatric malignancy, is generally never considered in the differential diagnosis of a paediatric malignant mediastinal mass. B-cell ALL presenting with an anterior mediastinal mass is extremely rare. Only two cases were reported in the literature , 2 with 3/uL), anaemia (7.6 g/dL), thrombocytopenia (20 × 103/uL) and 15% lymphoblasts on peripheral blood film. There was no evidence of laboratory or clinical tumour lysis syndrome (TLS). A chest CT scan and flow cytometry on peripheral blood were done and high-dose steroids (methylprednisolone) were started for the management of the superior mediastinal syndrome. The CT chest confirmed an anterior mediastinal mass . Orthopnoea started improving within 24 hours of steroid therapy and completely settled after 2 weeks. He also developed TLS and febrile neutropenia during induction chemotherapy. His day 29 minimal residual disease (MRD) showed less than 0.01% blasts and the post-induction CT scan showed complete resolution of anterior mediastinal mass with incidental finding of left eventration of the diaphragm. The patient successfully completed further cycles of chemotherapy with three episodes of febrile neutropenia. After 2 months of maintenance therapy, he was admitted with respiratory distress. It was suspected that he has developed bronchopneumonia but the chest CT-scan confirmed relapsed disease at the primary site of involvement . He was given supportive care but the condition rapidly deteriorated and the patient expired.This is the first reported case in a child with B-cell ALL presenting with superior mediastinal syndrome secondary to an anterior mediastinal mass. The index case is distinctive from the previous two reported cases  as it prThis is the first case of a paediatric B-cell ALL that presented with superior mediastinal syndrome secondary to an anterior mediastinal mass. This case concludes that B-cell ALL could also be a possible underlying diagnosis in paediatric anterior mediastinal masses. It also highlights the importance of early diagnosis before the development of life-threatening complications and advanced stage of disease at presentation.No conflicts of interest or funding to disclose.


Modeling muscle activity in the neck muscles of a finite element (FE) human body model can be based on two biological reflex systems. One approach is to approximate the Vestibulocollic reflex (VCR) function, which maintains the head orientation relative to a fixed reference in space. The second system tries to maintain the head posture relative to the torso, similar to the Cervicocolic reflex (CCR). Strategies to combine these two neck muscle controller approaches in a single head-neck FE model were tested, optimized, and compared to rear-impact volunteer data. The first approach, Combined-Control, assumed that both controllers simultaneously controlled all neck muscle activations. In the second approach, Distributed-Control, one controller was used to regulate activation of the superficial muscles while a different controller acted on deep neck muscles. The results showed that any muscle controller that combined the two approaches was less effective than only using one of VCR- or CCR-based systems on its own. A passive model had the best objective rating for cervical spine kinematics, but the addition of a single active controller provided the best response for both head and cervical spine kinematics. The present study demonstrates the difficulty in completely capturing representative head and cervical spine responses to rear-impact loading and identified a controller capturing the VCR reflex as the best candidate to investigate whiplash injury mechanisms through FE modeling.The online version contains supplementary material available at 10.1007/s10237-022-01616-y. Closed loop-based control has been used to control muscle activations in finite element (FE) human body models (HBMs) and has been shown to increase their biofidelity  can be implemented individually or in implementations where both systems act simultaneously in a single head-neck finite element (FE) model. In addition, optimization of the muscle co-contraction was also proposed and applied to the model to develop a model that can stay upright under gravitational acceleration before horizontal loads are applied. The effects of different approaches to combine active muscle controllers, including with and without muscle co-contraction, should be compared to find the best reproduction of kinematic data from volunteer testing.. The origin and insertions of the muscles were based on anatomical descriptions from Gray and Standring  software 4.0.4  and OriginPro 2019(64-bit) were used as pre- and post-processing software.The results of the muscle co-contraction optimization are presented in Table The results of KPA, KDA, TNDA, KPM, KDM, TNDM and their different configurations are presented in Table The lowest Derivative gain value was found for the model with MLF Controller only (0.186%contraction/mm ms-1). The highest Derivative gain was the APF controller in the Combined-Control approach (41.04%contraction/rad ms-1). The slowest (17.51 ms) and the fastest (3.50 ms) neural transmission and processing delay were assigned to APF Controller in the Combined Control approach and the model with MLF controller, respectively.Head displacements for the three degrees of freedom were compared for all controller implementations Fig. . For heaFigure All models with active muscle controllers improved overall head kinematics agreement with volunteer responses compared to the model without active muscle control (passive model) as shown by the CORA score values , the combined control always had the highest magnitude and was active earlier than the other strategies. This high magnitude could be because combining a vestibular inspired and muscle spindle feedback inspired controller was unsuitable using a simple minimum and maximum function. These investigated methods to incorporate the APF and MLF controllers can be considered pragmatic approaches. Several studies have implemented and combined VCR-like and CCR like controllers with various loading conditions  Below is the link to the electronic supplementary material.


We read with interest the article by Costa et al. reporting on coagulation factor Xa recombinant, inactivated-zhzo, which discusses optimal management strategies for the reversal of factor Xa (FXa) inhibitor-associated uncontrolled or life-threatening bleeding . We commCosta et al. excluded patients with a Glasgow Coma Score (GCS) less than 7. The mean GCS in the baseline demographics of this trial both before and after propensity score matching was 14. This leads the reviewer to debate the applicability of these trial results to patients presenting with more severe injuries. The exclusion of a GCS of 7 also leads the reviewer to have reservations regarding the trial’s endpoint of overall 30-day mortality rate. Patients presenting with a GCS of 14 are less likely to present with a large hematoma and therefore are expected to have less severe sequelae. Furthermore, the trauma subset included in this trial lacks details about the severity of injury that may provide insight to the reader. The trauma subset does not provide an injury severity score to frame our understanding of the injury. Without this detail, the reader is left uninformed of a significant nuance regarding baseline severity and therefore the efficacy of treatment. The relatively high GCS cutoff combined with the missing injury severity scoring in the trauma subset may lead the reader to conclude that the comparison between coagulation factor Xa recombinant, inactivated-zhzo and 4F-PCC on mortality is appropriate to apply in moderate-to-severe FXa inhibitor-associated life-threatening intracranial bleeding.The 4F-PCC weight-based dose suggested by the Society for Neurocritical Care Society and the Society of Critical Care Medicine in 2016 recommends 50 units/kilogram (kg) to prevent hematoma expansion . TherefoThe statistics in this trial utilize propensity matching to match patients in coagulation factor Xa recombinant, inactivated-zhzo arm from the ANNEXA-4 trial to serve as a synthetic control arm for the patients enrolled in the 4F-PCC group during this study period [We, therefore, caution that conclusions drawn about the comparison in hemostatic effectiveness and mortality in coagulation factor Xa recombinant, inactivated-zhzo versus 4F-PCC may be limited.


Improving the effectiveness of vaccines, which have limited success in the first weeks of life, is important for better protection of this vulnerable population2. One overlooked avenue to help achieve long-term protection from infectious disease is newborn immunization through breast milk. Here we bring forward a new paradigm where imbibing microbial antigen-containing milk is akin to the process of vaccination, which captures the act of vaccine delivery. Bioactive agents in milk have potential to function as adjuvants, enhancing the infant’s immune response against an antigen. The infant’s immune response to the human milk containing microbial antigens with adjuvant molecules is the equivalent of immunization, resulting in less susceptibility to disease3.Infants are at high risk for infectious diseases, which account for over one third of deaths in children under 5 years of age4. This major impact is attributed to its high content in a wide array of anti-infective compounds such as maternal antibodies, lactoferrin and human milk oligosaccharides. These factors provide invaluable help for the developing immune system and can kill pathogens, inhibit their proliferation or prevent invasion of the mucosa of the breastfed child4. In addition to providing short-lived protection, there is evidence that microbial antigens in human milk may represent the optimal characteristics for infant mucosal immunization4. More in-depth understanding in this field is key for the prevention of infectious diseases and the development of age-tailored vaccination strategies.Human milk is known to be the most potent way to prevent respiratory and gastro-intestinal infections4). More than 80% of children that are breastfed by HIV-positive mothers do not acquire HIV, despite ingesting HIV daily for several months to years. Importantly, these uninfected infants secrete HIV-specific IgG and IgA in the intestinal mucosa, demonstrating mucosal immune activation in response to HIV exposure through breast milk. In addition, almost half of them show HIV-specific IFN-γ responses in the blood, which persist after breastfeeding has ceased. These data remarkably illustrate that viral antigens in breast milk can stimulate both mucosal and systemic immunity in children, with an impact beyond the duration of breastfeeding. Supporting evidence for infant immunization through pathogen antigen shedding in breast milk is also found in maternal vaccination studies with live attenuated rubella virus. Rubella antigen is detected in the mother’s breast milk and infants born to rubella immunized mothers have rubella-specific IgG in serum and IgA in their nasopharyngeal secretions as well as virus-specific cellular immune reactivity in blood lymphocytes (reviewed in4). More recently, a study demonstrated development of mucosal immunity to SARS-CoV-2 in newborns breastfed by SARS-CoV-2 infected mothers, without any sign of infection in the offspring5. Parasitic antigens such as from Schistosoma mansoni6 and Plasmodium falciparum7 are also present in breast milk of infected women. While currently there is no data from birth cohorts on the possible immunization of children exposed to parasite antigen through breast milk, one study demonstrated better defence against S. mansoni in young adult mice when they had been nursed by S. mansoni-infected mothers8.The most striking observations of breast milk actively stimulating antigen-specific immune defences are related to maternal HIV infection (reviewed inA few studies shed light on the possible ways breast milk vaccination may work and provide the optimal route to activate the newborn’s immune system Fig. .Fig. 1Br9. The levels of P. falciparum antigen histidine-rich protein 2 and hepatitis B e antigen are 10-100-fold lower, and hepatitis B surface antigens are 30,000 times lower in human milk than in serum10. These low levels may be an important cue for the developing immune system of the neonate.The very low amounts of antigens in human milk may fit the specific requirements for activation of the developing immune system. Neonates mount an efficient cytotoxic immune response to a viral dose 10,000 times lower than an adult, while higher doses are unable to activate an appropriate immune response9.Exogenous proteins in human milk are pre-digested within the mammary gland. This process might be key for the generation of immunogenic peptides. As the newborn has only limited digestive abilities, predigesting pathogen-specific proteins in breast milk may be important for the newborn to generate a long-lasting and protective response9.The presence of both maternal pathogen-specific antibodies and pathogens in breast milk highly suggests the presence of pathogen antigen-immune complexes. Antigen-IgG antibody immune complexes improve the transport of pathogen across the gut barrier using the neonatal Fc receptor and enhance the stimulation of effector immune responses by antigen-presenting cells9. Human milk extracellular vesicles also express major histocompatibility complex molecules, which could contribute to the induction of antigen-specific immune responses in breastfed infants9.Antigen-presenting cells present in milk might play a role in the induction of a pathogen-specific immune response. Interestingly, the proportion of leucocytes in human milk increases upon maternal infection, which may increase pathogen-derived antigen presentation by milk antigen-presenting cellsFinally, microbes and microbial antigens in breast milk are surrounded by thousands of immune modulatory factors. The breast milk milieu contains molecules including antibodies and enzymes that can alter, weaken or reduce the viability of microbes present in the milk. This could lead to the generation of live attenuated pathogens that are fit to immunize the infant without infecting them. Among the bioactive compounds in breast milk are also potential strong adjuvants such as cytokines, the milk microbiota, soluble CD14 and Toll-like receptors.The complex and dynamic composition of breast milk may have specifically been selected for and adapted to the newborn’s situation, in order to effectively promote immune defence upon microbial antigen transfer in the milk.Rather than merely a potential vehicle for transmission of disease, breast milk likely acts as a route that activates the neonatal immune system to mount a protective, long-lasting response. Very few studies have considered that pathogens and their antigens in human milk may immunise offspring. Further research is required to conclusively establish whether and how human milk from infected or vaccinated mothers can immunise their offspring.Studies demonstrating active immunization of newborns through breastfeeding have important implications for maternal and child vaccination protocols. The knowledge can be used to develop infant-tailored, mucosal vaccines with an appropriate dose, adjuvant and form of the antigen for the developing immune system to react. In addition, maternal interventions to improve active immunization of newborns through breast milk, a physiological and needle-free route, are also in need of investigation. This includes improving antigen transfer into human milk and assessing storage and treatment conditions of expressed milk.With most preventable deaths in under 5 years old children due to infections and in the light of the current COVID-19 pandemic, stimulation of immunity to antigens from pathogens through breastfeeding makes for an invaluable field to explore.


Using Pd-mediated cross-coupling reactions, 2,2′-bipyridine units were attached at the periphery of diazafluorenemethylidene to obtain a multitopic ligand. UV-vis spectrosopic investigations along with electrochemical analyses reveal electronic communication along the conjugated path reflected in red-shifted absorption spectra and shifts of reduction potentials. The properties of the ligand could be manipulated by coordinating [Ru(bpy) Synthesis and structural characterization of a geminal enediyne molecule with three imine metal binding sites based on diazafluorenemethylidene in a cross-π-conjugated fashion is reported. The principal design of our approach based on a dibromoolefin building block25 allows for simple functionalization at the ene moiety as demonstrated recently with various protecting groups,26 bulky end-caps26 or redox-active fragments.27 The effective electronic communication observed in related architectures led us to design a molecular ligand that can serve as starting building block for large supramolecular ensembles.As the majority of literature-known systems provide metal bindings sites embedded in a linear π-conjugated fashion,In this report we use the diazafluorene core to access a cross-π-conjugated ligand with multitopic metal binding sites of different nature realized by introduction of 2,2′-bipyridines into the periphery of the diazafluorene unit .via a Sandmeyer reaction. Chemoselective coupling of 2  ethanol . After aca. 500 nm with absorption maxima at 314 and 388 nm. The shortest wavelength absorption maximum presumably arises from ethynylbipyridine centered transitions, as suggested by comparison of the spectral profile of this fragment 2]2+ fragments at all coordination sites. Here, the dominant interaction between the metal centres and the diazafluorene unit was reflected in the extended absorption range. The electrochemical results of both ligand and the complex suggest that the first reduction event based on the diazafluorene moiety influences the reduction ability of the complex, as a cathodic shift is observed for ethynylbipyridine parts in the ligand compared to the ethynylbipyridine molecule alone. Comparison of reduction potentials of ligand 7 and the corresponding complex 8 underlines further the effective communication along the conjugated path as an anodic shift of more than 600 mV is observed for the reduction of the diazafluorene and the ethynylbipyridine units. The different nature of metal binding sites within the molecule allows for selective coordination of metal centres, a topic of continuing interest in different fields such as photo-driven catalytic reactions.In summary, a cross-π-conjugated ligand bearing multitopic metal binding sites is synthesized by using Pd-mediated cross-coupling reactions. UV-vis spectroscopic analyses of the ligand revealed strong interaction between the different parts of the molecule In total, the persistent electronic communication in presented ligand design alongside the flexible synthetic modification of peripheral substituents allow for manipulating the properties of such ligand systems. In particular, the different nature of imine binding sites provided in ligand 7 paves the way to chemoselective control of coordination chemistry for various applications.There are no conflicts to declare.RA-010-D0RA06320G-s001


The function of the insula has been increasingly mentioned in neurocircuitry models of obsessive-compulsive disorder (OCD) for its role in affective processing and regulating anxiety and its wide interactions with the classic cortico-striato-thalamo-cortical circuit. However, the insular resting-state functional connectivity patterns in OCD remain unclear. Therefore, we aimed to investigate characteristic intrinsic connectivity alterations of the insula in OCD and their associations with clinical features.We obtained resting-state functional magnetic resonance imaging data from 85 drug-free OCD patients and 85 age- and sex-matched healthy controls (HCs). We performed a general linear model to compare the whole-brain intrinsic functional connectivity maps of the bilateral insula between the OCD and HC groups. In addition, we further explored the relationship between the intrinsic functional connectivity alterations of the insula and clinical features using Pearson or Spearman correlation analysis.Compared with HCs, patients with OCD exhibited increased intrinsic connectivity between the bilateral insula and bilateral precuneus gyrus extending to the inferior parietal lobule and supplementary motor area. Decreased intrinsic connectivity was only found between the right insula and bilateral lingual gyrus in OCD patients relative to HC subjects, which was negatively correlated with the severity of depression symptoms in the OCD group.In the current study, we identified impaired insular intrinsic connectivity in OCD patients and the dysconnectivity of the right insula and bilateral lingual gyrus associated with the depressive severity of OCD patients. These findings provide neuroimaging evidence for the involvement of the insula in OCD and suggest its potential role in the depressive symptoms of OCD.The online version contains supplementary material available at 10.1186/s12888-022-04341-z. Obsessive-compulsive disorder (OCD) is a severe and disabling mental disorder characterized by the obsession of recurrent, unwanted and intrusive thoughts, images or urges (obsessions) and excessively repetitive ritualistic behaviors or mental acts that individuals feel compelled to perform in response to obsessions according to rigid rules or to achieve a sense of completeness (compulsions) , 2. The In addition to the classical frontal-striatal circuit, limbic or affective processing regions such as the amygdala, insula, and hippocampus and their functional network with the classical circuit have been added to the neuroimaging model of OCD –8. CompaIn terms of neuroimaging studies, previous studies have revealed characteristic increased alterations in the structure and local function of the insula in patients with OCD , 18. HowTherefore, the objective of the current study was to discern the altered whole-brain intrinsic connectivity patterns of the insula by recruiting a relatively large sample of drug-naïve patients with no comorbidities to exclude the confounding effects of medication and comorbidities. Based on the previous functional neuroimaging findings for the insula in patients with OCD, we hypothesized that the intrinsic functional connectivity patterns of the insula would be elevated in OCD patients relative to healthy controls, and there would be a correlation between the abnormal neuroimaging features and the clinical information, especially the mood-related indicators.We recruited 85 unmedicated and comorbid-free OCD patients from the Mental Health Center, West China Hospital, Sichuan University. Two experienced psychiatrists diagnosed the OCD patients on the basis of the Structured Clinical Interview (SCID-I) for the Diagnostic and Statistical Manual of Axis I Mental Disorders, fourth edition (DSM-IV). The inclusion criteria were as follows:  age betwOf these 85 OCD patients, 71 patients were medication-naïve. The other 14 patients had received medication for the treatment of OCD , and all of them were medication free for at least 4 weeks before the MR scanning. The Yale-Brown Obsession-Compulsive Scale (Y-BOCS)  was usedIn addition, we enrolled 85 age- and sex-matched healthy controls (HCs) from the same sociodemographic circumstances via poster advertisements and examined them with the SCID nonpatient edition. The HC subjects and their first-degree relatives were free of any history or present neurological disorder or mental disorders.This study was approved by the Ethics Committee of West China Hospital, Sichuan University and the study is done in the accordance with the Declaration of Helsinki. Each participant provided written informed consent to accomplish this study after a complete description of the protocol.All participants were scanned using a 3.0-Tesla GE Signa EXCITE scanner equipped with an 8-channel phased-array head coil. Each subject was positioned comfortably in the coil fitted with soft earplugs and foam pads and was instructed to keep his or her eyes closed, remain motionless and do not think of any specific topic.3 and field of view (FOV) = 240 × 240 mm2. The rs-fMRI scans in the current study did not use field maps. The total acquisition time of the GRE-EPI images was approximately 6.67 min (400 s). Additionally, high-resolution T1-weighted 3D anatomical images were obtained with the following parameters: contiguous coronal slices = 156; slice thickness = 1.0 mm; TR = 8.5 ms; TE = 3.4 ms; flip angle = 12°; matrix size = 256 × 256, voxel size = 0.94 × 0.94 × 1 mm3 and field of view (FOV) = 240 × 240 mm2.For each individual, we acquired whole-brain resting-state functional magnetic resonance imaging (rs-fMRI) data using a gradient-echo echo-planar imaging (GRE-EPI) sequence with the following parameters : 30 axiahttp://rfmri.org/dpabi) [3 using unified segmentation of individual T1 images[The rs-fMRI data preprocessing was performed by the Data Processing and Analysis for Brain Imaging toolkit  . For eacg/dpabi) , 32, whig/dpabi) , includiT1 images. The proTo explore the abnormal resting-state functional connectivity of the insula to the voxels of the whole brain between the OCD and HC groups. We selected the bilateral insula as the seed regions of interest (ROIs) using the AAL atlas Fig. .http://resting-fmri.sourceforge.net. sourceforge.net). First, the regional time series averaged across all voxels within each seed were extracted. Then, Pearson’s correlation analysis of the time series was performed between the seed reference and the whole brain in a voxel-wise manner to obtain the intrinsic functional connectivity maps of each seed region for all participants. Finally, the subject-level correlation maps were z scored using Fisher r-to-z transformation before taking the average across subjects for further group-level analysis.Seed-based resting-state functional connectivity analysis was performed using the Resting-State fMRI Data Analysis Toolkit software package . The significance threshold was set as P < 0.005 (uncorrected) at the voxel level and a familywise error (FWE) corrected P < 0.025 (0.05/2) at the cluster level [P < 0.05).General linear model (GLM) was carried out to identify the distinct resting-state functional connectivity patterns of insula between OCD and HC groups, with the age, sex, and head motion as the covariates in SPM12 .The exploratory correlation analysis of the intrinsic functional connectivity strength extracted from the regions showing significant group differences with the duration of illness, age of onset, symptom severity measured by Y-BOCS , as well as HAMD and HAMA scores in the OCD group were performed to determine whether the insular rsFC abnormalities were correlated with the clinical characteristics. After the linear correlation conditional tests, including the Kolmogorov‒Smirnova normal distribution test, for variables that met the normal distribution and linear condition, we used the Pearson correlation, and those that did not meet the conditions we used the Spearman correlation. An FDR q value < 0.05 was considered statistically significant for multiple comparisons in this correlation analysis. (P = 0.504), sex  or head motion  between the two groups.The sociodemographic and clinical characteristics of the OCD and HC groups are provided in Table The results of two-sample t test analyses comparing the seed-based resting-state functional connectivity of insula between OCD and HC groups and the exploratory correlation analysis with clinical characteristics were as follows Fig. ; Table 2Compared to the HC group, patients with OCD showed significantly increased positive intrinsic functional connectivity of the left insula and a large cluster including the bilateral precuneus gyrus extending to the inferior parietal lobule. Additionally, we found another significantly enhanced positive intrinsic functional connectivity of the left insula and right supplementary motor area in OCD patients relative to HCs.In patients with OCD, we observed a significant increase in the positive resting-state functional connectivity between the right insula and the bilateral precuneus/inferior parietal lobule and supplementary motor area. Furthermore, the OCD patients displayed significantly reduced positive intrinsic functional connectivity of the right insula and bilateral lingual gyrus compared to HCs.After excluding 14 OCD patients with a history of previous medication, the results of the group comparisons between medication-naïve OCD patients (N = 71) and HC subjects (N = 85) were similar to the primary results from the whole OCD patient group   Fig. .In the current study, using the seed-based resting-state functional connectivity method, we revealed distinct patterns of intrinsic insular functional connectivity alterations in OCD. There were two main findings in this study. First, compared to the HC group, patients with OCD showed significantly increased intrinsic functional connectivity between the bilateral insula with a large cluster including the bilateral precuneus gyrus extending to the inferior parietal lobule and another cluster supplementary motor area. Significantly decreased intrinsic functional connectivity was found only between the right insula and bilateral lingual gyrus in OCD patients relative to HC, which was negatively correlated with HAMD scores rather than YBCOS scores in the OCD group. Our findings indicated the involvement of aberrant insular intrinsic connectivity in OCD patients, and more importantly, the dysconnectivity of insula may be related to the depressive symptoms rather than the obsession or compulsory manifestation in OCD.Relative to the HC group, the OCD patients showed increased intrinsic functional connectivity between the bilateral insula and bilateral precuneus extending to the inferior parietal lobule. The precuneus and inferior parietal lobule are both important core regions of the default mode network for integrating and processing self-referential information , 38. BecPatients with OCD demonstrated enhanced intrinsic connectivity of the bilateral insula and supplementary motor area compared with HC subjects. The supplementary motor area, which may be associated with the deficient inhibitory control of compulsory or obsessive behavior, has been found to be hyperactive in OCD patients according to prior studies , 45. In Significantly decreased intrinsic connectivity of the right insula and bilateral lingual gyrus was observed in OCD patients compared to HCs. The lingual gyrus is located in the visual cortex region and may contribute to emotional perception during visual stimulation and the further processing of complex visual information , 51. In Interestingly, we further observed that there was a trend of correlation between the reduced intrinsic connectivity of the right insula and lingual gyrus and the enhanced severity of depressive symptoms rather than OCD-related symptoms in the OCD group. Previous studies have reported reduced insular volume in OCD patients with comorbid depression , and theThe current study has several features that merit consideration in the interpretation of the results. First, our study had a cross-sectional design and was unable to investigate the long-term changes in insular connectivity patterns and the effects before and after treatments in OCD patients. In the future, longitudinal studies need to be performed to explore the functional connectivity of the same ROIs at baseline and after first-line treatments for OCD and verify the engagement of these regions in pharmacological and behavioral treatments. Second, our current results were derived from a single study, and future studies in unmedicated OCD samples with no comorbidities or comorbidities limited to depressive disorders are needed to replicate and validate our findings. Third, the correlation between the altered intrinsic connectivity of the insula and clinical features should be treated with caution, as they did not survive FDR correction for multiple comparisons. Note that these results still provide valuable insights that there is a trend for depressive symptoms in OCD to be associated with dysconnectivity of the insula, which could guide future research. Finally, this study used the entire insula region as the seed. However, several studies have implicated the distinct functions of different insular subregions . In futuUsing the seed-based resting-state connectivity approach, our present research identified alterations in the intrinsic connectivity patterns of the insula in OCD patients compared to healthy controls. We found that increased insular intrinsic functional connectivity mainly located in the bilateral precuneus gyrus and supplementary motor area, and decreased intrinsic connectivity only between the right insula and bilateral lingual gyrus, which was associated with the severity of depressive symptoms in OCD patients. Our findings provide the neuroimaging evidence for a pathophysiological role of the insula in OCD and suggest that future studies focusing on depressive manifestation in patients with OCD should consider the role of the insula in this regard.Below is the link to the electronic supplementary material.Supplementary Material 1: Supplementary Figure S1


Evidence suggest that greenspace use can be associated with children's physical, mental, social health, and well-being . Greenspace can facilitate a wide range of low-cost activities and the availability of greenspace is frequently linked to increased levels of recreational physical activity. Accordingly, contemporary children's declining greenspace use prompts a need to understand the factors that affect frequency of use.Aiming to determine to what extent demographic, environmental and social factors predict greenspace use for school-aged (6-15-year-old) children in Denmark, a national online survey was distributed to parents of 10.000 0-15-year-old children. From a total of 4772 responses a sub-sample of 3171 responses from parents of school-aged children was included in the analysis for this study. The aim was addressed by answering the following research questions: 1) How often do Danish children use greenspaces? 2) What demographic differences in greenspace use are present? 3) How do social and environmental factors predict greenspace use?Responses from the 3171 parents showed that 49.5% of the children used greenspace almost every day during the summer season. Multivariate binary logistic regression analysis showed that the number of types of greenspaces within walking or cycling distance from home was a strong predictor for daily use. Social factors  also predicted use, but less so. Geography and child age were the only demographic predictors for using greenspace almost every day.Findings from the present study suggest that providing opportunity for choosing between various types of greenspaces within walking or cycling distance might be an effective way to stimulate children's use of greenspace. Also, increased parental awareness of their role in children's outdoor spatial behaviours might further greenspace use among children.


Hyaluronic acid dermal fillers are a very popular choice for patients wanting to undergo non-invasive facial rejuvenation. Its prevalence is predicted to continue to rise. We report a case of delayed angioedema and associated urticaria to hyaluronic acid dermal fillers post COVID-19 infection. To our knowledge, this is an unusual case of hypersensitivity reaction of eight-month latency. Although the aetiology warrants further research, the author suggests utilisation of a four-week time window between dermal filler injections and COVID-19 vaccination. The recent pandemic with COVID-19 has increased the prevalence of delayed complications in association with hyaluronic acid dermal fillers. We present an unusual case of hypersensitivity reaction of eight-month latency in a clinically well patient who had hyaluronic acid dermal fillers. She has had similar dermal filler treatments multiple times in the past; however, she has never reported any reactions or adverse effects.We present a case of a 55-year-old healthy female who developed a COVID-19 infection which did not require hospitalisation. She was treated with dermal fillers at multiple sites  for facial rejuvenation in July 2020. The hyaluronic acid dermal fillers that were injected by the clinician were monophasic in nature, 20mg/mL concentration, and crosslinked. She has been having dermal filler treatments for the past five years and never reported any reactions or adverse events. She has no medical history nor is she on any medication.The patient began to develop flu-like symptoms and subsequently tested positive for the COVID-19 using a polymerase chain reaction test. Surprisingly, thirteen days later she developed angioedema of the lower face and lips as well as urticaria of the hands despite not having had any dermal filler treatments for 8 months. Upon clinical examination, she was asymptomatic with regards to COVID-19 but there was firm swelling palpated at the site of the previously injected dermal fillers, except over the zygomatic region. She was managed with oral corticosteroids  and high-dose antihistamines (40mg cetirizine daily) which eventually allowed the swelling to subside. Hyaluronidase was kept on standby but was not required given the marked improvement of the swelling and tenderness in the first 24 hours. Symptoms completely resolved by day 25 without the need of dissolving the hyaluronic-acid dermal fillers with hyaluronidase (Figure Hyaluronic acid is generally known to be a biocompatible, non-immunogenic linear polysaccharide made from N-acetyl-d-glucosamine and glucuronic acid . It has In our case, a medically well patient at the age of 55, was treated with hyaluronic acid dermal fillers for facial rejuvenation. She was not injection-naive as has never reported any acute or delayed complications in the past. With her last treatment being eight months previously, surprisingly she developed an alleged delayed reaction to the dermal fillers. A thorough clinical history revealed the likelihood of COVID-19 infection and, subsequently, she was antigen positive. What is unusual in this particular case is the presence of urticaria on the patients' hands. it is difficult to conclude the exact aetiology of this; however, one explanation could be the breakdown of hyaluronic acid into smaller fragments causing a systemic inflammatory response. It is important to consider differential diagnoses of late-onset nodules, foreign body granulomatous reactions, and biofilms.The literature review highlighted that three patients reported facial and lip swelling after receiving the Moderna COVID-19 vaccine - two had cheek fillers 6 months prior to being vaccinated and one had lip filler two days post-vaccine . Each ofThe authors recommend thorough screening of patients prior to receiving the COVID-19 vaccine, for example, discussions with patients seeking cosmetic treatments who are yet to receive the vaccine. From our experience, we suggest there is a time window to minimise the risk of adverse reactions - a minimum of four weeks between dermal filler injections and vaccination in those who are deemed low risk and potentially longer in those who have risk factors, for example, immunological disorders. Furthermore, we advise that clinicians take a detailed clinical history in patients with a record of receiving hyaluronic acid dermal filler treatments as COVID-19 infection may manifest with cutaneous symptoms such as angioedema and urticaria.We presented a case of delayed hypersensitivity response to dermal fillers post COVID-19 infection. Cutaneous reactions to both the COVID-19 infection and vaccine may be an early sign of dermatologic sequelae as more of the global population gets vaccinated. The exact aetiology of delayed reactions in relation to dermal fillers and COVID-19 remains unclear and warrants further research and discussion.


Aspirin and related drugs with anti-inflammatory effects have lung cancer prevention effects in laboratory studies and through their use in populations at risk for lung cancer. We studied aspirin plus zileuton compared to two placebo pills for 3 months in smokers. We studied genes associated with lung cancer, smoking, and lung disease. We used nasal swabs to collect nasal cells that were smoke exposed to look for changes in these genes. We found that most of the gene panels in the nasal cells related to smoking and lung cancer lung disease did not change in a favorable way, but we did see a favorable change in a gene panel representing abnormal squamous cells that may progress to lung cancer. We think this finding is of interest and can be studied further using deep lung biopsies to understand if this drug effect occurs where squamous cell lung cancer actually starts.The chemopreventive effect of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) on lung cancer risk is supported by epidemiologic and preclinical studies. Zileuton, a 5-lipoxygenase inhibitor, has additive activity with NSAIDs against tobacco carcinogenesis in preclinical models. We hypothesized that cyclooxygenase plus 5-lipoxygenase inhibition would be more effective than a placebo in modulating the nasal epithelium gene signatures of tobacco exposure and lung cancer. We conducted a randomized, double-blinded study of low-dose aspirin plus zileuton vs. double placebo in current smokers to compare the modulating effects on nasal gene expression and arachidonic acid metabolism. In total, 63 participants took aspirin 81 mg daily plus zileuton (Zyflo CR) 600 mg BID or the placebo for 12 weeks. Nasal brushes from the baseline, end-of-intervention, and one-week post intervention were profiled via microarray. Aspirin plus zilueton had minimal effects on the modulation of the nasal or bronchial gene expression signatures of smoking, lung cancer, and COPD but favorably modulated a bronchial gene expression signature of squamous dysplasia. Aspirin plus zileuton suppressed urinary leukotriene but not prostaglandin E2, suggesting shunting through the cyclooxygenase pathway when combined with 5-lipoxygenase inhibition. Continued investigation of leukotriene inhibitors is needed to confirm these findings, understand the long-term effects on the airway epithelium, and identify the safest, optimally dosed agents. Lung cancer is the leading cause of cancer-related deaths both in men and women in the US and worldwide. An estimated 228,820 new cases of lung cancer and 135,720 deaths due to lung cancer are projected to occur in the US in 2020. LTE4 (1 ng)) and extracted with C18 solid-phase extraction columns. The eluate from solid-phase extraction was dried and reconstituted in an aliquot of methanol and filtered using a 0.2 µm Spin-X filter. The filtrate was dried and reconstituted in an aliquot of methanol/water (50/50) prior to injection onto the LC-MS system. The chromatographic separation was achieved by a C18 reverse-phase column and a gradient mobile phase of ammonium acetate, acetic acid, and acetonitrile. The mass spectrometer was operated in negative ion mode utilizing electrospray ionization. Detection was achieved using selected reaction monitoring, with the transition of m/z 438 to 333 monitored for LTE4 and the transition of m/z 441 to 336 for the internal standard. The assay was linear over the range of 6.25–2500 pg/mL with an assay accuracy of >90% and an inter-assay coefficient of variation of <12%.The urinary LTE4, the terminal product of 5-LOX-mediated AA metabolism, was quantified by a sensitive and specific liquid chromatography tandem mass spectrometry assay . BrieflyUrinary biomarker levels were normalized by urinary creatinine concentrations measured using a creatinine assay kit (Diazyme Laboratories).Total RNA was isolated from nasal brushings using a Qiagen miRNeasy Mini Kit following the manufacturer’s instruction. Quality control and quantification of the RNA samples were performed using an Agilent BioAnalyzer and NanoDrop spectrophotometer. The total RNA was processed and hybridized to Affymetrix Human Gene 1.0 ST Arrays.n = 127 samples, n = 43 subjects) using R statistical software (version 3.6.0) and the Robust Multiarray Average (RMA) algorithm (affy package) [n = 4). limma [Gene expression values were generated for each Human Gene Arrays 1.0ST CEL file (package)  with Entpackage) . Standar). limma  was usedn = 190)), residual gene expression values, as previously described [For each previously published gene expression signature (“signature data”), the corresponding processed gene expression data used to derive the signatures was downloaded from the Gene Expression Omnibus (GEO). Specifically, we downloaded the following datasets: GSE16008 for the smoking-associated gene expression signature derived from nasal and bronchial brushings, GSE80796 for the lung cancer-associated gene expression signature derived from nasal brushings, GSE7895 for the smoking-associated gene expression signature derived from bronchial brushings, GSE12815 for the PI3K activity signature, GSE37147 for the COPD-associated gene expression signature derived from bronchial brushings, GSE79209 for the squamous dysplasia-associated signature derived from bronchial brushings, and GSE109743 for the proliferative molecular subtype signature derived from endobronchial biopsies and reflected in the bronchial brushings. For GSE79209 and GSE109743 . The relationship between the differentially expressed genes with ASA plus zileuton treatment at the end-of-treatment and one-week post-treatment points was assessed using Gene Set Enrichment Analysis (GSEA) [n = 38 subjects, n = 114 samples).A linear mixed effect model implemented in limma was used to identify differentially expressed genes associated with ASA plus zileuton at the end-of-treatment or one-week post-treatment points. The main effects in the model were treatment (ASA plus zileuton or placebo), timepoint , the interaction between treatment and timepoint, RIN, and batch (samples were processed in 3 batches). Patient was modeled as a random effect using the limma ‘duplicateCorrelation’ function. Genes signatures associated with ASA plus zileuton at the end-of-treatment and one-week post-treatment points were identified based on empirical Bayes moderated s (GSEA)  using ras (GSEA)  hallmarks (GSEA)  for eacht-test was used to test for significant differences in changes in the gene signature scores between the treatment and placebo groups. Based on a sample size of 20 per group, the power will be at least 85% to detect an effect size of ≥1  at a significance level of 5%. A two-sided two-sample t-test was also used to compare the baseline values of the gene signature scores between the intervention arms and the baseline values of PGEM and LTE4 and changes in the PGEM and LTE4 levels between the intervention arms. A two-sided paired t-test was performed to evaluate the changes in the gene signature scores, PGEM, and LTE4 overall, by intervention arm, and by gender. All secondary analyses are considered exploratory so no correction for multiple comparisons was used. The Fisher’s exact test was used to compare the frequency of adverse events (AEs) between the intervention and placebo arms.For a given endpoint, evaluable participants were defined as those that received the intervention and had three time points available for deriving changes within the same subject and then comparing the changes between the two groups. A two-sided two-sample https://clinicaltrials.gov/ProvidedDocs/03/NCT02348203/Prot_SAP_000.pdf (accessed on 19 April 2022).The protocol is available at: n = 31; 18 male/13 female) or placebo   participants in the combined ASA and zileuton arm and 22 (69%) in the placebo arm completed the study intervention with complete sets of biospecimens. The baseline characteristics of the randomized participants are summarized in In total, 21 (68%) participants in the combined ASA and zileuton arm and 22 (69%) in the placebo arm completed the study intervention with complete sets of biospecimens. The baseline characteristics of the randomized participants are summarized in p = 0.03) between the intervention arms for participants with gene signatures. There were no significant differences by the intervention arm for body mass index (BMI), pack year tobacco exposure, or race/ethnicity for all participants or for those with evaluable gene signatures.Nasal specimens from 19 (61%) and 21 (66%) participants in the combined ASA and zileuton arm and placebo arm, respectively, yielded high-quality RNA and microarray data across all three time points  and thus constituted the evaluable cohort for changes in the gene signature scores. The baseline characteristics of the cohort evaluable for gene signature scores are summarized in All but three participants had high baseline urinary cotinine levels consistent with self-reported current heavy tobacco use, with similar levels between arms and which remained high over the duration of the study (data not shown).Participants in both arms took greater than 90% of the assigned pills on average by pill count. The ASA plus zileuton intervention was overall well tolerated. All adverse events (AEs) were grade 1 or 2 events treated with supportive care intervention and were self-limited . There wThe attrition rate for the ASA and zileuton arm was 10/31 and 10/32 for the placebo arm; reasons included lost to follow-up, withdrew consent, non-compliance, and AE. The two AEs that were associated with participant withdrawal from the study were abdominal pain grade 2  and seizure grade 2 .n = 19 participants in the ASA and zileuton arm and 21 participants in the placebo arm). Data for the primary endpoint analysis of modulation of the smoking-associated gene expression signature score derived from nasal and bronchial brushings [Gene expression data from the nasal brushings of participants in the ASA and zileuton and placebo arms was scored based on several lung-associated gene expression signatures, including signatures associated with smoking, lung cancer, COPD, and bronchial dysplasia, derived from bronchial and nasal brushings and endobronchial biopsies see . Particirushings  are summp = 0.26). Scores derived from a bronchial signature associated with the presence of squamous dysplasia [There was no significant change in this gene signature score at the end of the intervention compared to baseline in the ASA and zileuton versus placebo groups   . Data fop < 0.001 . LTE4 baseline levels were higher for females than males for both treatment arms. For the combined ASA and zileuton intervention, PGEM levels decreased from baseline to the end of the intervention, but this was not statistically significant   a,b. For  < 0.01) .(a)p < 0.01). The heatmap shows hierarchal clustering of the z-score-normalized change in the gene expression between the end-of-treatment and baseline time points for each subject in the aspirin and zileuton (green) or placebo (purple) arms (n = 38 subjects).In total, 83 genes were associated with the end of the aspirin and zileuton treatment compared with baseline ((b)p < 0.01). The heatmap shows hierarchal clustering of the z-score-normalized change in the gene expression between the one-week post-treatment and baseline time points for each subject in the aspirin and zileuton (light green) or placebo (light purple) arms (n = 38 subjects).In total, 139 genes were associated with the one-week post aspirin and zileuton treatment time point compared with baseline ((c)x-axis) and the gene sets represent the genes that were up- and downregulated one week after the aspirin and zileuton treatment from (b). The black vertical lines represent the position of the genes in the ranked list (x-axis) and the height corresponds to the magnitude of the running enrichment score form GSEA (y-axis).Genes that were altered at the end of the aspirin and zileuton treatment compared with baseline are concordant with the genes that were altered one week after the aspirin and zileuton treatment by GSEA (FDR < 0.05), suggesting that changes persist for at least one week post-intervention. Genes were ranked by the moderated t-statistic for the effect of the end of the aspirin and zileuton treatment versus baseline ((d)x-axis) and one week after (y-axis) the aspirin and zileuton treatment. Positive and negative scores represent pathways enriched among upregulated and downregulated genes with the end of (yellow) and one week after (blue) or both (green) aspirin and zileuton treatment, respectively.Ranked lists (genes ranked by moderated t-statistics) for the end-of-treatment and one-week post-aspirin and zileuton treatment versus baseline effects were used for pathway enrichment analysis via GSEA using the MSigDB hallmark gene set. The scatterplot shows the normalized enrichment scores for pathways enriched (FDR < 0.25) at the end of  < 0.05, n = 12 pathways, FDR < 0.25) and one week after the ASA plus zileuton treatment . Pathways associated with oxidative phosphorylation, reactive oxygen species, MYC targets, DNA repair, and MTORC1 signaling were enriched among downregulated genes and KRAS signaling and myogenesis were enriched among upregulated genes with the ASA plus zileuton end-of-treatment and one-week post-treatment time points (p > 0.05).Interestingly, pathway analysis also indicated an overlap between the genes that were modulated at the end of ASA plus zileuton treatment  intervention is broadly consistent with a number of preclinical biomarker studies of NSAIDs and other classes of chemoprevention agents in murine models of cigarette smoke exposure ,44. WhilThe combined ASA and zileuton intervention significantly suppressed AA 5-LOX-derived metabolite urinary LTE4 levels compared with the placebo arm in females only. While a study of zileuton pharmacokinetics showed that gender effects on the pharmacokinetics were absent after a correction for bodyweight differences , an effeLD ASA and zileuton was, in general safe, and well tolerated, with minimal GI toxicity and no evidence of GI bleeding, in keeping with studies using the NSAID naproxen, which showed that combined blockade of COX and 5-LOX did not produce additive GI AEs typically associated with naproxen administration, and reports of reduced GI toxicity associated with dual COX/5-LOX inhibitors such as licofelone . There wA weakness in the study design is the lack of quality of life (QOL) endpoints, which could elucidate the impact of this ASA plus zileuton strategy on QOL and thus guide similar chemoprevention strategies with the goal of, at the most, a modest impact on QOL in an at-risk but otherwise healthy population. A second weakness in the study design is the inability to better inform the optimal duration of the intervention to modulate the study endpoints, given that the single duration intervention was short (3 months). Additional cohorts utilizing longer durations of intervention  would have strengthened the study.Our study showed that LD ASA and zileuton compared to placebo modulated a bronchial squamous dysplasia gene signature but had no significant effects on other known carcinogenesis gene signatures in the nasal epithelium of heavy smokers. Inhibition of the leukotriene pathway remains of interest in the chemoprevention of squamous PMLs. Nasal gene expression signature determination is a novel approach to biomarker analysis, giving an approximation of the pulmonary milieu without the requirement of invasive tissue sampling. Nasal brushing of the nasal epithelium was well tolerated in this study and offers the potential to perform mechanistic lung cancer prevention studies in a less invasive way. This approach should be further explored with concomitant bronchial biopsies to determine if modulation of the squamous dysplasia gene signature can replace bronchoscopic biopsy for endpoint determination in future chemoprevention trials.


Understanding how and why de-implementation of low-value practices is sustained remains unclear. The Paediatric Research in Emergency Departments International CollaboraTive (PREDICT) Bronchiolitis Knowledge Translation (KT) Study was a cluster randomised controlled trial conducted in 26 Australian and New Zealand hospitals (May-November 2017). Results showed targeted, theory-informed interventions  were effective at reducing use of five low-value practices for bronchiolitis  by 14.1% in acute care settings. The primary aim of this study is to determine the sustainability (continued receipt of benefits) of these outcomes at intervention hospitals two-years after the removal of study supports. Secondary aims are to determine sustainability at one-year after removal of study support at intervention hospitals; improvements one-and-two years at control hospitals; and explore factors that influence sustainability at intervention hospitals and contribute to improvements at control hospitals.n = 20) and New Zealand (n = 6) hospitals, which participated in the PREDICT Bronchiolitis KT Study. Data for a total of 1800 infants from intervention and control sites (up to 150 per site) will be collected to determine if improvements  were sustained two- years (2019) post-trial ; and a further 1800 infants from intervention and control sites will be collected to determine sustained improvements one- year (2018) post-trial (secondary outcome). An a priori definition of sustainability will be used. The qualitative component will consist of semi-structured interviews with three to five key emergency department and paediatric inpatient medical and nursing staff per site . Factors that may have contributed to sustaining outcomes and/or interventions will be explored and mapped to an established sustainability framework.A mixed-methods study design. The quantitative component is a retrospective medical record audit of bronchiolitis management within 24 hours of emergency department (ED) presentations at 26 Australian (This study will improve our understanding of the sustainability of evidence-based bronchiolitis management in infants. Results will also advance implementation science research by informing future de-implementation strategies to reduce low-value practices and sustain practice change in paediatric acute care.Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820. Contributions to the literatureThis will be one of the few studies examining sustainability (continued receipt of benefits) and sustainment (continued use) of an intervention that improved evidence-based practices in acute care settings.Findings will contribute knowledge of the factors that improve the sustainability of evidence-based management of infants with bronchiolitis.Understanding effective sustained implementation strategies will inform future efforts to improve practice in acute care settings as well as future implementation research.In infants less than 1 year of age, the most common lower respiratory tract infection is bronchiolitis , 3. In AP < .001) [Recommended management of bronchiolitis is well defined, comprising of supportive practices such as respiratory and hydration support , 3, 9. T < .001) . The focsustainability and sustainment [Sustainability studies are rare, with the few undertaken reporting poor long-term (sustained) compliance , 18. Thitainment . For ourtainment , 23. We tainment , 23.To date, measurement of the ongoing effect of implementation research largely reports success by the ‘clinical outcomes’ that the intervention was designed to change  . Often tA wide variety of terms,  have previously been used when discussing sustainability . HoweverThe ‘Knowledge Translation (KT) in Australasian Paediatric Acute Care Settings Study’ (PREDICT Bronchiolitis KT study) (ACTRN12616001567415) was a multi-centre, cluster randomised controlled trial conducted in 26 Australian and New Zealand hospital Emergency Departments (EDs) and paediatric inpatient areas during the 2017 Southern Hemisphere bronchiolitis season (1st May to 30th November 2017), involving 3240 infants . Both inP < .001) [Findings of the PREDICT Bronchiolitis KT Study demonstrated that, when compared with control hospitals, intervention hospitals significantly improved adherence in management of bronchiolitis during the acute care period  for the five key low-value practices as per Australasian Bronchiolitis Guideline recommendations  . Specifi < .001) . At triaThe aim of this mixed methods study is to: i) determine if the use of the targeted theory-informed interventions from the PREDICT Bronchiolitis KT Study have been effective at sustaining improvements  in the care of children with bronchiolitis during the acute care period  1 and 2 years post-trial completion, specifically in 2018 and 2019, at intervention group hospitals; ii) determine if there are any improvements to adherence to the Australasian Bronchiolitis Guideline in control group hospitals; iii) understand the factors that influence the sustainability of improvements in intervention group hospitals and; iv) explore factors which may have contributed to improvements at control group hospitals. We will use an a priori definition of sustainability .A mixed-methods study design will be used. Retrospective medical record audits will assess the sustainability of the improvements, and qualitative semi-structured individual or group interviews will assess the sustainment of the interventions.The original twenty-six hospitals  which participated in the 2017 PREDICT Bronchiolitis KT Study will be invited to participate . HospitaClinical Directors of EDs or general paediatric inpatient units whose hospital participated in the PREDICT Bronchiolitis KT Study will be approached by email to assess interest and capacity for their hospitals to be involved in this study . The resA retrospective patient medical record audit will be conducted by designated site study staff at each consenting site, under the supervision of site Principal Investigators. A list of all infants who presented between 1 January 2018 and 31 December 2019 with International Classification of Diseases 9th and 10th revision (ICD-9 or ICD-10) discharge codes for bronchiolitis  will be collected at 2 years post-trial (2019), to address the primary outcome. Similarly, data from 1800 infants will be collected at one-year post-trial (2018). If a site has less than 150 infant presentations per year, 100% of eligible infants will be selected. If a site has more than 150 infant presentations per year, a random sample of 150 infants per year will be selected by an independent statistician using computer software.Adherence with all five Australasian Bronchiolitis Guideline Recommendations (composite outcome) known to have no benefit  when an infant presents with bronchiolitis in the acute care period  at two- years (2019) following the completion of the PREDICT Bronchiolitis KT Study in intervention hospitals ;Primary Outcome:2.Adherence with all five Australasian Bronchiolitis Guideline Recommendations (composite outcome) known to have no benefit  when an infant presents with bronchiolitis in the acute care period  at one- year (2018) following the completion of the PREDICT Bronchiolitis KT Study in intervention hospitals ;3.Adherence with all five Australasian Bronchiolitis Guideline Recommendations (composite outcome) known to have no benefit  when an infant presents with bronchiolitis in the acute care period  at 3a) one- year (2019) following provision of study materials, study results, and ‘Train the Trainer’ education  ; and 3b)Secondary Outcomes:The periods of one- and two- years following delivery of the intervention will be measured from the post-trial completion date of 30th November 2017.Routinely collected bronchiolitis management data will be retrospectively extracted from medical records by designated site study staff. De-identified data extracted from the medical records will be entered into a standardised form in a Research Electronic Data Capture (REDCap) database by designated study staff at each hospital.The sample size for this medical record audit will depend on the number of participating hospitals and will be recalculated upon completion of the hospital recruitment stage. Based on our previous study , assuminExploratory Objectives will be run to estimate the marginal differences in proportions of no use of all five low-value practices between the study groups, using Generalised Linear Mixed (GLM) [Exploratory Objectives will examine adherence to the five individual practices ; difference between intervention and control groups in 2019; difference between intervention and control groups in 2018; and trends over time  that hospitals were randomly allocated in the previous study . Absoluted (GLM) . If the me Table .Table 3EAn a priori definition of sustained improvements will be based on the 7% median improvement achieved in the PREDICT Bronchiolitis KT Study . PracticThe Clinical Director of either the EDs or paediatric inpatient areas of the participating hospital will be approached by email to confirm their hospital’s participation in the qualitative interviews. The Clinical Director  will be requested to send participant information forms to eligible medical and nursing staff. Phone or email contact with the Clinical Directors or site Principal Investigator will be made by the research team approximately 1 week after sending the recruitment pack to check receipt and facilitate recruitment.Qualitative group interviews will be undertaken with a purposive sample of nurses and doctors at each hospital who treat infants with bronchiolitis in participating EDs and paediatric inpatient areas. These will be undertaken at intervention and control group hospitals at each site or via telephone/video interviews. Where it is not possible to undertake semi-structured group interviews at the hospital due to logistical issues or COVID-19 restrictions, interviews will be undertaken with individual staff members. To be eligible for interview, participants must be: on an active practice roster; working full-time or part-time in a clinical role as either registered nurses or doctors who care for children with bronchiolitis in New Zealand or Australian EDs or paediatric inpatient areas. The original PREDICT Bronchiolitis KT Study clinical leads will be included in the sample, where possible . Bank orFactors that contributed to sustainability/non-sustainability of improvements  at intervention group hospitals 4 years post-trial completion including the sustainment of PREDICT Bronchiolitis KT Study implementation strategy;Factors that contributed to improvements  or deterioration at control group hospitals 4 years post-trial completion, including the use of PREDICT Bronchiolitis KT Study implementation strategy;Fidelity to and adaptation of the PREDICT Bronchiolitis KT Study implementation strategy at intervention and control group hospitals 4 years following intervention delivery  .Eligible ED and paediatric inpatient area staff will contact the research staff directly, by email or phone, so a convenient date, time and location for the individual or group semi-structured interview can be arranged. Participants will be interviewed face-to-face or by video link , depending on the participants’ preferences and convenience. Consent will be implied if an eligible interested individual presents at the agreed upon time to participate in the semi-structured interview. The interviews will be conducted for approximately 30-45 minutes and will be digitally recorded using a voice recorder or via zoom . Verbal confirmation will be obtained for consent to audio-tape the interview.The interview schedule has been developed by the research team, which includes emergency physicians, nurses and researchers. The schedule includes open-ended questions to elicit participant’s views on how the PREDICT Bronchiolitis KT Study was perceived by staff; use and adaption of intervention materials; and potential barriers and enablers to sustaining practice change. The interview schedule will be piloted to ensure face and content validity.n = 78 to 130) from a cross section of nursing and medical staff from both ED and paediatric inpatient areas will be invited to participate in the interviews.A maximum of three to five individuals per site , using an iterative process and open coding relating extracts of text to key questions using saliency analysis i.e., the extent to which each code occurs, and implied importance (regularly mentioned or considered important by researchers or participants) . HospitaThis study aims to evaluate if targeted, theory-informed interventions sustain improvements in bronchiolitis care  in the acute care period  in EDs and paediatric inpatient units, two-years (2019) after their implementation . ResultsWithin the field of implementation science, de-implementation is an emerging field of research, only appearing in the literature within the last decade , 39. The’ definition of sustainability and are using an established sustainability framework which has been deemed as relevant and useful when exploring sustainability in acute care settings [This study is novel and innovative as it examines the sustainability of a successful de-implementation intervention in the acute care setting, two- years following removal of the study supports. We will report sustainability of clinician behaviour changes and sustainment of evidence-based interventions to de-implement low-value care. Whilst there is no consensus on when implementation phases end and when the sustainability period commences , 20, 30,settings , 29. As


Adolescent self-harm in Europe is a major public health challenge and shares a risk continuum with suicide. Recent research demonstrates a strong risk correlation with attempting suicide in the community-based adolescent self-harm population group, similar to research findings for populations in health setting-based research. In the UK increasing rates in hospital admissions represent the “tip of the iceberg” within the community, with potentially two thirds of the population group not accessing health services for support. This brings many health risks, including an increased suicide risk. Finding a solution to these issues requires a preventative intervention approach for young people, including community-based delivery to address service access barriers. Secondary schools are posited as key settings where this type of support could be delivered. But emerging UK research demonstrates challenges in completing adolescent self-harm research with young people in schools.This paper centres on a current adolescent self-harm preventative intervention research project in Cardiff University. It focuses on ethical research practice in community-based adolescent self-harm research.This paper appraises some of the core ethical issues, challenges and their management in completing adolescent self-harm prevention intervention research in secondary school settings in Wales. It also provides an overview of the project’s innovative safety protocol design.This project was successful in managing the potential risks to the school-based adolescent research participants.This work helps address some of the current research barriers to completing adolescent self-harm prevention intervention research in schools, to facilitate shared solutions to the urgent public health challenge of adolescent self-harm.