Glucose management is challenging in patients who require nutritional support in hospital. We aimed to assess whether fully closed-loop insulin delivery would improve glycaemic control compared with conventional subcutaneous insulin therapy in inpatients receiving enteral or parenteral nutrition or both.ClinicalTrials.gov, number NCT01774565.We did a two-centre (UK and Switzerland), open-label, randomised controlled trial in adult inpatients receiving enteral or parenteral nutrition (or both) who required subcutaneous insulin therapy. Patients recruited from non-critical care surgical and medical wards were randomly assigned (1:1) using a computer-generated minimisation schedule  to receive fully closed-loop insulin delivery with faster-acting insulin aspart (closed-loop group) or conventional subcutaneous insulin therapy (control group) given in accordance with local clinical practice. Continuous glucose monitoring in the control group was masked to patients, ward staff, and investigators. Patients were followed up for a maximum of 15 days or until hospital discharge. The primary endpoint was the proportion of time that sensor glucose concentration was in target range (5·6–10·0 mmol/L), assessed in the intention-to-treat population. This trial is registered with Between Feb 8, 2018, and Sept 21, 2018, 90 patients were assessed for eligibility, of whom 43 were enrolled and randomly assigned to the closed-loop group (n=21) or the control group (n=22). The proportion of time that sensor glucose was in the target range was 68·4% [SD 15·5] in the closed-loop group and 36·4% [26·6] in the control group . One serious adverse event occurred in each group (one cardiac arrest in the control group and one episode of acute respiratory failure in the closed-loop group), both of which were unrelated to study interventions. There were no adverse events related to study interventions in either group. No episodes of severe hypoglycaemia or hyperglycaemia with ketonaemia occurred in either study group.Closed-loop insulin delivery is an effective treatment option to improve glycaemic control in patients receiving nutritional support in hospital.Diabetes UK, Swiss National Science Foundation, National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome Trust, and European Foundation for the Study of Diabetes. Nutritional support with enteral or parenteral nutrition is an important component of medical care.Hyperglycaemia occurring in inpatients receiving parenteral or enteral nutrition, with or without a history of diabetes, is associated with increased morbidity and mortality.Clinical practice guidelines for inpatient glucose management in non-critical care have been proposed,Evidence before this studyWe searched PubMed for articles published from Jan 1, 2000, up to Dec 1, 2018, using the search terms  AND  to identify previous studies on the management of inpatient hyperglycaemia in non-critical care. Two previous inpatient studies have investigated the use of closed-loop insulin delivery in patients with type 2 diabetes in non-critical care. The larger of these randomised controlled trials was done in 136 adult patients with type 2 diabetes and compared conventional subcutaneous insulin therapy with closed-loop insulin delivery in non-critical care. Over a period of up to 15 days, the proportion of time spent in the target glucose range (5·6–10·0 mmol/L) and mean blood glucose concentrations were significantly improved with closed-loop therapy, without an increase in hypoglycaemia. Our search did not yield any previous studies that used closed-loop insulin delivery in hospital inpatients receiving nutritional support. Alternative strategies to improve glucose management in patients receiving nutritional support include the use of variable-rate intravenous insulin infusion; however, this support is associated with increased staff workload. In a non-randomised prospective study of 605 inpatients receiving parenteral nutrition, intravenous insulin  was associated with a greater risk of hypoglycaemia compared with subcutaneous or no insulin therapy. Overall glucose control was not reported. A retrospective study showed suboptimal glucose control using intravenous insulin infusion to treat parenteral nutrition-related hyperglycaemia in the non-intensive care setting. Subcutaneous insulin pump therapy titrated every 4 h has shown benefits in glycaemic variability over multiple daily insulin injections titrated every 4 h in a randomised trial involving 102 post-surgical patients receiving parenteral nutrition in hospital, but it requires substantial input from health-care providers and does not provide glucose concentration feedback. Studies have shown that insulin availability is affected by the composition of the parenteral nutrition infusion containers (adsorption with plastic-containing surfaces is much greater than with glass). The presence of a multivitamin and trace element additive is associated with much greater insulin availability than parenteral nutrition solutions without additive. The GLUCOSE-in-PN randomised trial showed no difference in mean glucose concentration achieved with continuously infused insulin in parenteral nutrition compared with subcutaneously administered long-acting insulin in non-critically ill surgical patients receiving parenteral nutrition.Added value of this studyOur study is, to our knowledge, the first to assess fully automated closed-loop insulin delivery without meal bolusing in adults in non-critical care receiving enteral or parenteral nutrition (or both). We showed that an increased proportion of time was spent in the target glucose range and mean glucose was reduced with fully closed-loop insulin delivery compared with standard insulin therapy, without an increase in the time spent in hypoglycaemia or the total daily insulin dose. This study shows that fully closed-loop insulin delivery can potentially provide health-care professionals with an effective and safe clinical tool to manage hyperglycaemia in patients receiving parenteral or enteral nutritional support in hospital.Implications of all the available evidenceClinical guidelines for inpatient glucose management in non-critical care have been published. However, data from inpatient audits and studies show that implementation is challenging, particularly in patients receiving enteral or parenteral nutrition. Unanticipated dislodgement of feeding tubes, temporary discontinuation of nutrition, and cycling of nutritional support with oral intake necessitate high levels of vigilance among health-care professionals, including frequent blood glucose monitoring and regular adjustment of insulin doses. Glucose management in this population is associated with increased workload for ward staff, and fear of hypoglycaemia often leads to suboptimal glycaemic control. Further studies are needed to assess the potential of closed-loop insulin delivery to improve clinical outcomes, including morbidity and mortality, in this setting.Closed-loop systems, which automatically deliver insulin in a glucose-responsive manner, might provide a solution to glucose management for hospital inpatients requiring nutritional support. Closed-loop systems combine real-time glucose measurements from a continuous glucose monitoring (CGM) device with a control algorithm that directs insulin delivery via an insulin pump. Evidence that closed-loop technology improves glycaemic control in inpatients with hyperglycaemia is increasing, but systematic investigations in the most challenging circumstances, such as during parenteral or enteral nutrition, have not been done.11Here we report the results of a two-centre, randomised, open-label trial of fully closed-loop insulin delivery in a diverse cohort of inpatients receiving enteral or parenteral nutrition (or both) in non-critical medical and surgical care. We hypothesised that closed-loop insulin delivery would be safe and improve glycaemic control without increasing the risk of hypoglycaemia.In this two-centre, open-label, randomised controlled trial, participants were recruited from non-critical care wards at Addenbrooke's Hospital  and Bern University Hospital . Included patients were aged 18 years or older, had a prescription for enteral or parenteral nutrition, and had inpatient hyperglycaemia requiring subcutaneous insulin therapy during hospital admission. Exclusion criteria were type 1 diabetes, pregnancy or breastfeeding, and any physical or psychological disease or the use of one or more medication likely to interfere with the conduct of the trial or interpretation of the results. Full inclusion and exclusion criteria are available in the Eligible participants were randomly assigned (1:1) to either fully closed-loop insulin delivery with faster-acting insulin aspart (closed-loop group) or conventional subcutaneous insulin therapy . Randomisation was done with the minimisation method, generated by Minim randomisation software,Participant bodyweight, height, and total daily insulin dose were recorded after enrolment. The study did not alter or specify the nutrition regimens prescribed by the local clinical team, and participants did not have their usual activity restricted.In the closed-loop group, participants' usual insulin therapy and sulfonylurea medication, if prescribed, was discontinued on the day of closed-loop initialisation. All other medications were continued. A subcutaneous cannula was inserted by the investigator in the abdomen or arm for delivery of faster-acting insulin aspart  by a study pump . A subcutaneous real-time CGM sensor  was inserted in the upper arm or abdomen by the investigator and calibrated in accordance with the manufacturer's instructions. When sensor glucose data became available, fully closed-loop glycaemic control was started by the investigator. A low glucose sensor alarm on the CGM receiver was initialised at a threshold of 3·5 mmol/L.The FlorenceD2W-T2 automated closed-loop system consisted of a model predictive control algorithm (version 0.3.70) residing on a control algorithm device  linked by a Universal Serial Bus cable to the CGM receiver  were done by ward nursing staff in accordance with to local clinical practice.At the end of the closed-loop period, participants completed a brief questionnaire providing feedback on their satisfaction with glycaemic control while on closed-loop therapy, acceptance of wearing study devices, and whether they would recommend closed-loop therapy to others. Participants' usual insulin therapy and sulfonylurea medication were restarted at the end of closed-loop use as appropriate.In the conventional insulin therapy group, participants' insulin therapy at randomisation and other antihyperglycaemic therapies were continued throughout the study period. A CGM sensor (Freestyle Navigator II) was inserted by the investigator on the first day of the study and calibrated in accordance with the manufacturer's instructions.Point-of-care capillary glucose measurements  were done by ward nursing staff. Each participant's glycaemic control was managed by the participant's clinical team in accordance with local clinical practice. The clinical team were allowed to modify and adjust participants' insulin and other antihyperglycaemic therapies and initiate additional point-of-care capillary glucose measurements as appropriate. Both centres have an inpatient diabetes service and patients in the control group referred to the diabetes team had capillary glucose reviewed every 1–2 days depending on patient complexity, with insulin doses adjusted as required. Patients not referred to the inpatient diabetes team had capillary glucose monitored and insulin dose adjusted by the clinical team.Closed-loop insulin delivery was continued for up to 15 days or until hospital discharge. To reflect local clinical practice, in the UK, closed-loop insulin delivery was stopped if nutritional support was stopped and the diabetes team deemed that subcutaneous insulin therapy was no longer required; data collection was stopped at this point in both closed-loop and control groups. In Switzerland, data collection continued in both closed-loop and control groups up to 15 days or until discharge.The primary outcome was the proportion of time the sensor glucose measurement was in the target glucose range of 5·6–10·0 mmol/L during the study period. Secondary outcomes were the proportion of time that the sensor glucose measurement was either higher or lower than the target range; the proportion of time it was higher than 20·0 mmol/L, lower than 3·9 mmol/L, lower than 3·0 mmol/L, and lower than 2·8 mmol/L; the burden of hypoglycaemia, assessed by the area under the curve (AUC) less than 3·5 mmol/L and less than 3·0 mmol/L; the mean sensor glucose measurement; and the total daily insulin dose.Secondary outcome measures of glycaemic variability was assessed by the SD and the coefficient of variation in sensor glucose measurements using data collected from the whole study period. The between-day coefficient of variation in sensor glucose measurements was calculated from daily mean glucose measurements (midnight to midnight). Daytime (0800–0000 h) and overnight (0000–0800 h) results were calculated for a subset of prespecified exploratory outcomes  to limit multiple comparisons. The mean pre-meal and pre-bed capillary glucose measurements at each defined period were calculated per participant for the whole study period. Daily carbohydrate intake was calculated, and route of delivery recorded, per participant for the study period. Assessment of the experience of participants in the closed-loop group was collected at the end of the study period.Safety endpoints were severe hypoglycaemia (<2·2 mmol/L) and clinically significant hyperglycaemia (>20 mmol/L) with ketonaemia, as determined by point-of-care capillary measurements, as well as device deficiencies, adverse events, and serious adverse events. Since the study was done in hospital inpatients, many of whom had a serious health condition or life-threatening illness at enrolment, only unanticipated adverse events and events relating to the study interventions were reported.This was an exploratory study in which we planned for up to 45 patients to be randomly assigned. Since previous inpatient closed-loop studies might not provide reliable information about the SD of the primary endpoint in patients receiving parenteral or enteral nutrition (or both), we applied no formal power calculation. The sample size corresponds to the sample size of a previous inpatient feasibility closed-loop randomised trial.t test was used to compare normally distributed variables and the Mann-Whitney U test was used for highly skewed variables. We tabulated the numbers of events (a prespecified saftey outcome) that were related to a capillary glucose measurement of less than 3·5 mmol/L, less than 2·2 mmol/L, and more than 20 mmol/L in each trial group and we compared the proportion of participants with events in each group with Fisher's exact test. We report values as mean (SD) or median (IQR), unless stated otherwise. We made no allowance for multiplicity. All p values are two-tailed, and p values of less than 0·05 were deemed to indicate statistical significance.We analysed efficacy and safety data by an intention to treat. We calculated outcomes with GStat software (version 2.3) and did statistical analyses with SPSS (version 25). An unpaired ClinicalTrials.gov, number NCT01774565.This trial is registered with The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. CKB, LB, and RH had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors made the decision to submit for publication.From Feb 8, 2018, to Sept 21, 2018, 90 participants were considered for enrolment, of whom 43 were eligible and consented; 21 were randomly assigned to the closed-loop group and 22 to the control group . Across vs 55%), and participants in Cambridge were younger and had higher baseline HbA1c .The baseline characteristics of the closed-loop group and control group were similar . The prone HbA1c . The mosne HbA1c . Gastroine HbA1c . The meane HbA1c . Total hThe study duration, defined as the period from the first sensor reading until last sensor reading, was similar between groups  was significantly higher in the closed-loop group (68·4% [SD 15·5]) than in the control group  and daytime (0800–0000 h) sensor glucose concentration was in the target range was significantly higher in the closed-loop group than in the control group  of 21 participants in the closed-loop group . Overall, 100% (17/17) of those who completed the questionnaire stated that their diabetes treatment in hospital during the study was as expected or better than expected and 100% reported that having their glycaemia controlled automatically by the closed-loop system was as expected or better than expected . All 17 Four hypoglycaemic episodes with capillary glucose concentration of less than 3·5 mmol/L, confirmed by point-of-care measurements, occurred in the closed-loop group (two participants), compared with nine episodes in the control group (five participants). These episodes were treated with oral or enteral carbohydrates in accordance with local guidelines by the ward staff, with intravenous dextrose required in one episode  because of a reduced level of consciousness and a blocked nasogastric tube. As per protocol, one patient in the closed-loop group received supplemental insulin in accordance with the instruction of the study team when sensor glucose was greater than 18 mmol/L for more than 1 h.No episodes of severe hypoglycaemia or significant hyperglycaemia with ketonaemia occurred in either group. Two severe adverse events (one cardiac arrest and one episode of acute respiratory failure resulting in death) occurred during the study (one case of acute respiratory failure in the closed-loop group and one case of cardiac arrest in the control group); neither was related to the study . No adveIn this randomised controlled trial, we have shown that fully closed-loop insulin delivery provided significantly better glycaemic control than did conventional subcutaneous insulin therapy in inpatients on enteral or parenteral nutrition (or both) in non-critical care. The proportion of time that the sensor glucose concentration was in the target range was significantly greater in the closed-loop group than in the control group, and the mean sensor glucose and SD were significantly lower in the closed-loop group. Improved glycaemic control was achieved without increasing the risk of hypoglycaemia and without an increase in total daily insulin dose.Recommended glucose targets in non-critical care are not attainable by many health-care institutions with conventional insulin therapy.17Our study shows that overnight insulin requirements were higher in patients receiving nutritional support than in previous closed-loop inpatient studies,Alternative approaches to improving glucose management in this population include use of variable-rate intravenous insulin infusion; however, this method requires considerable staff workload with up to 2 h per 24 h period spent monitoring blood glucose and adjusting insulin infusion rates, precluding widespread use on general wards.Between-night sensor glucose variability was reduced with closed-loop therapy use compared with conventional therapy, but between-day sensor glucose variability did not differ significantly between groups. This result reflects the advantage of frequent modulation of insulin delivery based on sensor glucose, trading variability of insulin delivery with consistency in glucose concentration. Previous studies have shown that higher glycaemic variability (measured by the SD and mean daily change in blood glucose) increases the risk of mortality in inpatients receiving parenteral nutrition.Identifying populations most likely to benefit from closed-loop glycaemic control is likely to be important for widespread adoption of this technology in the inpatient setting. Our findings expand on the results of a randomised trial that investigated use of a fully closed-loop system in an unselected cohort of inpatients with hyperglycaemia.Acceptability of closed-loop systems in the inpatient setting has been positive and the system has been designed to limit effects on mobility. Many inpatients require tubes and attachments for treatment of comorbidities other than diabetes. Future closed-loop systems will have a substantially smaller device burden. Implementation of closed-loop systems in the inpatient setting will require training for ward nursing staff. Set-up, initialisation, and day-to-day management of the closed-loop system do not require specialist input. However, administration of intravenous insulin, which is currently undertaken by ward nursing staff, is more complex and has a higher risk of dosing error and health consequences. Future studies should assess to what extent the adoption of closed-loop technology adds to the complexity of staff duties. Surveillance for efficacy and safety will be possible with the remote monitoring capabilities of newer closed-loop platforms, allowing remote review of multiple patients on closed-loop systems across the hospital. Limitations to adoption include clinical inertia and time required to train health-care professionals. Studies showing clinical benefit from closed-loop glycaemic control should help to overcome these barriers.The strength of this study is the use of a novel approach to address the need for effective and safe management of hyperglycaemia in one of the most challenging inpatient populations. In the control group, glycaemic control was managed in accordance with local hospital guidelines, reflecting real-world practice. The two-country design allowed the safety and efficacy of fully closed-loop glycaemic control to be assessed across different health-care systems, supporting generalisability. The closed-loop system used commercially available components, allowing ease of use in different health-care settings and potentially allowing accelerated adoption of the system for future widespread clinical use.The study design was pragmatic because of the heterogeneity of the study population, allowing individualised treatment intensification on a patient-by-patient basis in the control group and reflecting usual clinical practice in the two centres. Insulin regimens and the frequency of glucose monitoring varied within the control group. Both centres had an inpatient diabetes service and patients in the control group referred to the diabetes team had capillary glucose measurements reviewed every 1–2 days depending on patient complexity, with insulin doses adjusted as required, whereas patients not referred to the inpatient diabetes team had capillary glucose monitoring and insulin dose adjustment done by the clinical team. The target glucose range varies for hospital inpatients in non-critical care. Tight glycaemic control is associated with increased mortality in the intensive care setting because of an increased risk of hypoglycaemia.This study has limitations, including the small number of patients. Sensor glucose data availability was higher in the closed-loop group than in the control group. In the closed-loop group, the research team were notified of any loss of connectivity between sensor and receiver device by an alarm, whereas the glucose sensor was masked in the control group and such connectivity interruptions were not detected, leading to reduced sensor glucose data.In conclusion, we have shown that fully closed-loop insulin delivery in inpatients receiving parenteral or enteral nutrition (or both) is safe and significantly improves glycaemic control without increasing the risk of hypoglycaemia compared with conventional insulin therapy in non-critical care. Further studies are required to assess whether closed-loop glycaemic control can translate into improved clinical outcomes and is cost-effective in particular patient cohorts to support widespread adoption by health-care systems.No additional data are available.


Hypomesus transpacificus) is rapidly approaching extinction in the San Francisco Estuary, placing it in the crossfire between human and environmental uses of limited freshwater resources. Though managed as a semi-anadromous species, recent studies have challenged this lifecycle model for Delta Smelt, suggesting the species is an estuarine resident with several localized “hot-spots” of abundance. Using laser-ablation otolith strontium isotope microchemistry, we discovered three distinct life-history phenotypes including freshwater resident (FWR), brackish-water resident (BWR), and semi-anadromous (SA) fish. We further refined life-history phenotypes using an unsupervised algorithm and hierarchical clustering and found that in the last resilient year-class, the FWR (12%) and BWR (7%) comprised a small portion of the population, while the majority of fish were SA (81%). Furthermore, the semi-anadromous fish could be clustered into at least four additional life-history phenotypes that varied by natal origin, dispersal age and adult salinity history. These diverse life-history strategies should be incorporated into future conservation and management efforts aimed at preventing the extinction of Delta Smelt in the wild.Effective conservation of endangered species requires knowledge of the full range of life-history strategies used to maximize population resilience within a stochastic and ever-changing environment. California’s endemic Delta Smelt ( In fishes, diadromy, or the ability to migrate between freshwater and saltwater for the purpose of reproduction, is a common strategy employed to minimize predation risk on small vulnerable young in one habitat, while maximizing growth and reproductive output in another, thereby maximizing lifetime fitness3. In temperate climates the most common form is anadromy, where adults live in the ocean for several years prior to returning to freshwater for reproduction 4. However, some anadromous species stop short of migrating to the sea and rear in brackish estuarine habitats6. Regardless of the direction of movement, the migratory period is a critical part of the lifecycle in diadromous species where substantial risks from both natural  and anthropogenic factors  can occur, creating unique challenges for managing and protecting these species.Species have evolved complex life history strategies to utilize spatially and temporally variable environmentsOncorhynchus mykiss)11. Similarly, individuals can exhibit considerable variation in outmigration timing, time-at-sea, return timing and size and age at maturity14. Indeed, this diversity of intra and inter-population life histories can provide populations and species with a degree of stability during periods of poor environmental conditions and resilience following returns to periods of more favorable environmental conditions18. However, for declining or endangered species, such life-history diversity may be lacking, limiting their ability to respond to improved conditions or management actions employed to recover the species. This may be particularly important when such life-history diversity is cryptic and conservation strategies are aimed to benefit only one life-history strategy.To spread the risk of catastrophic mortality among habitats, many anadromous species exhibit diverse life history pathways whereby some individuals choose to remain resident in fresh water while others migrate to the sea, such as Steelhead Trout (Hypomesus transpacificus) is one of the most socio-politically important species in the Western United States and is nearing extinction in the wild22. This small, 2–3 inch cucumber-scented fish is endemic to the upper San Francisco Bay-Delta Estuary (SFE), where spawning habitat coincides with the State Water Project (SWP) and Central Valley Project (CVP) pumping facilities which provide fresh water for 23-million people and irrigation for a multi-billion-dollar agriculture industry21. Despite numerous protections, conservation efforts, and ecological studies over the past three decades, the population has continued to decline and is now at less than 1% of its historic abundance23. At times, large numbers of Delta Smelt become entrained in the CVP pumping facilities and other water diversions and killed. This can occur during their upstream spawning migration into fresh water in the late winter and in spring when the larvae reach a size which can be counted in the fish collection facilities at SWP and CVP25. To protect the species from excessive loss, pumping is restricted from January to June and can be shut down for periods of time when large numbers of fish are entrained, leading to delays or shortages in water deliveries24. In addition, freshwater flows into the estuary are required to maintain suitable low-salinity nursery habitat downstream of the agricultural diversions during the late summer and fall months. Collectively, these protections reduce the amount of water available for urban and agricultural use, causing significant political conflict and controversy regarding the efficacy of such expensive actions21.The Delta Smelt  can record the chemical composition of the ambient water and have been used extensively in estuarine fishes for tracking movements38. Otoliths have several features that are useful for life history reconstructions; (1) they accrete continuously through life resulting in daily age increments (in the early-life) of calcium carbonate and protein matrix, (2) incorporate elements of the surrounding environment into the calcium carbonate and protein matrix, (3) are biologically inert, (4) and grow in proportion to fish growth allowing for size reconstructions producing a life-long record of growth and environmental conditions. Strontium is an abundant trace element readily substituted for calcium in the mineral lattice, resulting in Sr concentrations and 87Sr/86Sr values that reflect the ambient water chemistry41. The ratio of radiogenic 87Sr to the stable 86Sr in rivers and lakes has proven to be a powerful tracer of provenance in many species because it varies predictably between different watersheds as a function of the age and geochemical composition of the underlying geology45. In the SFE, 87Sr/86Sr reflects the conservative mixing of fresh water from the Sacramento and San Joaquin rivers with the Pacific Ocean and has been used to reconstruct the salinity history of individual fish46. Moreover, 87Sr/86Sr has been shown to provide high resolution for reconstructing rearing from freshwater to low-salinity (<6 PSU) habitats in the upper SFE, where greater than 90% of all Delta Smelt occur.Determining the full range of Delta Smelt life-history strategies is critical for devising effective management and conservation strategies for the species. Unfortunately, the species is too small and delicate for traditional tagging methods87Sr/86Sr from the core (hatch) to the edge (catch) to reconstruct age-resolved 87Sr/86Sr chronologies. This analytical approach can provide detailed high-resolution time series of individual life histories but can also lead to computational challenges when evaluating large numbers of individuals. Furthermore, prior studies have primarily relied on professional judgement or qualitative assessment of 87Sr/86Sr profiles, which can be challenging when attempting to characterize life-history patterns among a large number of individuals. Therefore, we employed an unsupervised time-series algorithm, the Discrete Wavelet Transform, that can efficiently decompose complex time series into shorter, simpler segments while retaining the important time-dependent changes in chronologies47. The simplified chronologies were then used in hierarchical agglomerative clustering to identify groups of individuals with similar 87Sr/86Sr chronologies. The objective of the present study was to describe life-history patterns and their key attributes among a large number of individuals collected during a year when population abundance rebounded from prior low abundance observed during drought  with profiles of otolith ght Fig. . The app87Sr/86Sr profiles of Delta Smelt caught between September 2011 and May 2012 by monitoring surveys, in what was the last year of high abundance for this species up to date  and brackish water (>0.5 PSU) is at ~0.7075 . All freshwater resident fish (cluster 1) were captured in the perennial freshwaters of the northern Delta signifying individuals within this cluster completed their lifecycle in freshwater ,  had the lowest AICc of all examined models  and varied by sex and capture region  in 1986, which dramatically reduced phytoplankton and zooplankton abundance69. Furthermore, capture of sediments by dams70 and invasive aquatic vegetation65, and reduced resuspension due to decreasing wind velocities71 have reduced turbidity throughout much of the Delta, resulting in clearer waters that are less suitable for Delta Smelt. suitability of the LSZ has declined due to reduced sediment supply to the estuary70, increased capture by invasive submerged aquatic vegetation65 and decreasing wind patterns71. Preferred zooplankton prey are now more abundant in freshwater year-round72, suggesting fish rearing in the LSZ may be at a disadvantage; however, Hammock, et al.73 found that Delta Smelt feeding success was higher in brackish habitats in the fall and winter, suggesting semi-anadromous fish were capable of foraging successfully despite lower prey abundance. Furthermore,  they found growth rates for Delta Smelt in the brackish habitats of Suisun Bay and Suisun Marsh were similar or higher than other regions in some years. Thus semi-anadromous fish continue to utilize the LSZ as evident by their larger contribution to the population59.The Delta Smelt’s semi-anadromous life-history strategy was originally described as an adaptation to take advantage of high zooplankton prey abundance in highly turbid brackish waters (1–6 PSU) found in Suisun Bay and Suisun Marsh, commonly referred to as the Low-Salinity Zone (LSZ)87Sr/86Sr data during the natal period suggest Delta Smelt can utilize brackish habitats successfully for larval rearing; however, the vast majority of adults in this study reared as larvae in freshwater habitats. Delta Smelt are tolerant of brackish water during the juvenile, sub-adult and adult life stages76, however, the physiological tolerance of larval Delta Smelt has not been tested in the laboratory. While we may infer natal origin from otolith 87Sr/86Sr in the otolith core, we cannot be certain our data supports spawning in brackish habitats. Using a 3-D hydrodynamic particle tracking model Kimmerer, et al.77 showed that planktonic organisms could be dispersed rapidly, 10–25 km per day, thus a newly hatched larvae could be dispersed into brackish water within a few days post-hatch. However, we found approximately 50% of brackish and semi-anadromous clusters remained in brackish water through the spawning season, many of which had late stage gonads (stage IV-VI) at capture according to field-based assessment of gonad stage79. Furthermore, Kurobe, et al.79 measured 17β-estradiol from livers of females and found late stage maturity (late stage IV) corresponded with spikes in 17β-estradiol, which suggests fish were ready to spawn. Delta Smelt are capable of seasonal batch-spawning, producing multiple clutches of eggs with a refractory period lasting on the order of 40–50 days80. Given the patterns in life history and reproductive biology, individuals may spawn in both brackish water and freshwater within a reproductive season further spreading the risk of catastrophic mortality across habitats.Our otolith 29. The diversity of life histories observed in the study may provide insights into the species’ ability to rebound during periods of good environmental conditions. The estuary experienced high freshwater inflows in 2011, which resulted in greater volume and overlap of the LSZ with marsh habitats found in Suisun Bay. This increased volume of the LSZ corresponded with two groups of Delta Smelt with natal 87Sr/86Sr consistent with this very low (0.5–1 PSU) salinity. In dry years the volume of this habitat would be reduced and distributed upstream into the narrow-deep channels of the Sacramento-San Joaquin confluence, which likely results in limited production in this marginal habitat. Furthermore, summer water temperature in 2011 was relatively cool, which may have allowed freshwater resident fish to have greater survival and contribution to the adult population. Combined, the cool temperatures and above normal precipitation likely facilitated a greater contribution from more life histories in 2011 allowing the population abundance to increase. Unfortunately, drought conditions began in 2012 resulted  in low abundances and, despite wet conditions in 2017, the population failed to rebound. The population is now at such low abundance that long-term monitoring surveys are struggling to find the fish in the wild. Thus, while life-history diversity may provide some measure of resilience in this species, the degree of habitat alteration and additional stressors continue to depress the population.The life-history patterns found in this study provide definitive evidence for the original semi-anadromous designation; however, we also found evidence of resident life histories suggesting that Delta Smelt can also occur as population “hot spots” as described by Murphy and Hamilton30. Management for this species has come primarily in the form of freshwater flow and export regulations, however; these contentious actions have had mixed results thus far. Given this new description of Delta Smelt life history, conservation efforts need to take a multi-pronged approach to restore habitats in both freshwater and the brackish areas of the upper estuary. Restoration actions may come in the form of both physical habitat rehabilitation and reconnections with marsh habitats, but also freshwater flow actions to provide greater overlap of low-salinity habitat with dynamic physical habitats. While marsh restoration and flow management are available tools for species management in the estuary, rising temperature is an issue that is increasingly becoming intractable. Ultimately, the conservation and recovery of the Delta Smelt will require substantial changes to the management of the estuary, including major tradeoffs between users of California’s natural resources.Delta Smelt continue to exhibit life history diversity despite near-complete loss of historic habitat across the species' range. However, this hidden life history diversity has led to significant conflict and controversy over how to best manage and conserve this speciesHypomesus transpacificus) collected by the CDFW Interagency Ecological Program for scientific purposes pursuant to Fish and Game Code (FGC) 2081 (a). The portions of the study relating to Delta Smelt were approved by the Institutional Animal Care and Use Committee, University of California, Davis and followed the methodology in the approved protocol (IACUC Protocol #18175). All samples received were archived and reported in according with the CESA MOU and all methods and procedures used in this study were performed in accordance with the guidelines and regulations established in the IACUC protocol.A California Endangered Species Act (CESU) Memorandum of Understanding (MOU) was made and entered into by and between James Hobbs of the University of California, Davis (permittee) and the California Department of Fish and Wildlife (CDFW). The purpose of the CESA MOU was to authorize the permittee to obtain and possess Delta Smelt (Delta Smelt were collected from the San Francisco Estuary (SFE) across their entire known geographic range by the California Department of Fish and Wildlife (CDFW) during their 2011 Fall Midwater Trawl (FMWT: Sep-Dec) and 2012 Spring Kodiak Trawl (SKT: Jan-May) surveys Fig. . A total81. Sagittal otoliths were extracted from the fish, cleaned, and sanded with wet-dry sandpaper until the daily age rings were visible. Otoliths were then imaged at 20X magnification and otolith increments were measured along the dorsal plane approximately 90 degrees from the anterior-posterior axis. Otolith strontium isotope ratios (87Sr/86Sr) were analyzed at the UC Davis Interdisciplinary Center for Plasma Mass Spectrometry (UCD/ICPMS) using a multi-collector inductively coupled plasma mass spectrometer (Nu Plasma HR) interfaced with a Nd:YAG 213 nm laser (New Wave Research UP213). A laser beam of 40 µm diameter traversed across the otolith from ~100 µm before the core to the dorsal edge at 10 µm/s following the same direction as the aging profile  to predict the 87Sr/86Sr onto the age transect, resulting in a daily time series of 87Sr/86Sr values for each fish.Sample preparation and analyses was conducted following established protocols 87Sr/86Sr chronologies  when entire profiles were less than 0.7075, as semi-anadromous (SA) when the natal period (first 30-days post hatch) was less than 0.7075 and at older life-stage greater than 0.7075, and as brackish-water origin (BWR) when the natal and whole-life profiles were greater than 0.7075. Note that we did not use the otolith edge 87Sr/86Sr values in this classification scheme as some fish exhibited clear changes in 87Sr/86Sr values that would be interpreted as a return to freshwater from low-salinity in the late winter, but many samples did not show this despite being caught in freshwater, thus life history assignments are from hatch to the sub-adult phase. To determine complete life-cycle migrations we used capture region and salinity-at-capture along with otolith edge 87Sr/86Sr values to infer returns to freshwater.Distinct life history patterns were readily apparent upon visual inspection of ies Fig. . We used87Sr/86Sr chronologies. The daily resolved life history chronologies were decomposed into shorter, simpler chronologies using a Discrete Wavelet Transform (DWT) with a Haar wavelet. The use of wavelets has gained increasing use in non-stationary time series analysis as this approach can efficiently decompose a complex signal on local time-scales, retaining the time-dependent nature of the data while providing simplification of the signal83. The DWT has been used successfully in many fields including economics, computer science, and ecology to decompose time series into coefficients that allow for more efficient comparisons of low and high frequency variation85. Wavelet coefficients from the approximation sub-bands at the first level of decomposition were used to calculate Euclidean distance measures between age-matched individuals. Groups of fish were identified using the Euclidean distance measures in an agglomerative hierarchical clustering algorithm using the Ward’s method. We limited the cluster tree to 6 nodes to minimize the number of clusters while capturing an adequate level of life history detail. The DWT and agglomerative hierarchical clustering were performed using the tsClust package in R47. One limitation of this approach is that all time series examined need to be the same length for clustering, thus we trimmed otolith chronologies to the first 170 days of age. We chose this length of time because the oldest/latest fish to have moved from freshwater to brackish water based on the supervised approach was 143 days of age. We chose a buffer of 30-days to ensure inclusion of sufficient post-transition signal while also minimizing the number of fish removed from the unsupervised analysis.The second approach to assign life history used an unsupervised hierarchical time series clustering algorithm to group individual fish based on their 86. The life history cluster and age-at-transition from changepoint analysis was verified by visual inspection of 87Sr/86Sr chronologies and we found strong agreement between the unsupervised assignments and expert opinion assignments.To determine when fish migrated, we used changepoint analysis with AMOC (at most one changepoint) on all fish classified as semi-anadromous with the threshold or DWT87Sr/86Sr age-0 to age-30, (2) age-at-dispersal from fresh to brackish habitats , and (3) post-dispersal 87Sr/86Sr (age-140 to age-170) reflective of fish living among different salinity zones. We tested group differences using these three life history characteristics with non-parametric permutational MANOVA and assessed classification using Jackknife reclassification success of individuals to their respective life history groups using quadratic discriminant function analysis.We examined variability between DWT clusters using three key life history characteristics: (1) natal origin et al.78. These stages were further aggregated into early- (I–III) and late- (IV–VI) stage gonads. Since our subsample of fish from this survey included in the hierarchical clustering was small relative to the total number of fish captured representing a description of full life histories, we also modeled the probability of maturity (logistic regression) as a function of Julian date, sex, and region  for all fish caught to explore whether regional differences in reproductive development supported a model of upstream migration for the purposes of reproduction. Of the possible models using these predictors, we used the following model:2 and χ2 tests.To evaluate whether Delta Smelt exhibit semi-anadromous upstream migrations from brackish waters to fresh waters for reproduction, we explored reproductive stage of fish included in our hierarchical clustering along with the capture region and sex. Reproductive state of all adult Delta Smelt collected during the 2012 SKT survey  was assessed by CDFW and staged as I-immature to VI-spent according the protocols developed in Damon, Supplementary Information


Cross-species analysis of protein-protein interaction (PPI) networks provides an effective means of detecting conserved interaction patterns. Identifying such conserved substructures between PPI networks of different species increases our understanding of the principles deriving evolution of cellular organizations and their functions in a system level. In recent years, network alignment techniques have been applied to genome-scale PPI networks to predict evolutionary conserved modules. Although a wide variety of network alignment algorithms have been introduced, developing a scalable local network alignment algorithm with high accuracy is still challenging.We present a novel pairwise local network alignment algorithm, called LePrimAlign, to predict conserved modules between PPI networks of three different species. The proposed algorithm exploits the results of a pairwise global alignment algorithm with many-to-many node mapping. It also applies the concept of graph entropy to detect initial cluster pairs from two networks. Finally, the initial clusters are expanded to increase the local alignment score that is formulated by a combination of intra-network and inter-network scores. The performance comparison with state-of-the-art approaches demonstrates that the proposed algorithm outperforms in terms of accuracy of identified protein complexes and quality of alignments.The proposed method produces local network alignment of higher accuracy in predicting conserved modules even with large biological networks at a reduced computational cost. G= where V is a set of labeled nodes representing proteins and E is a set of edges representing interactions between proteins.The genome-wide study of proteins has considered the whole set of relationships between them on a system level as they form a complex network of interactions. A graph-theoretic model is commonly used to represent a set of protein-protein interactions (PPIs). A PPI network is a graph Recent research in this area has focused on systematic comparison of PPI networks of different organisms. This type of computational analysis is called network alignment. The network alignment problem includes finding the entire mapping of nodes and conserved edges between the mapped node pairs within two or more networks. This problem can be applied to PPI networks because interactions between proteins are ideally conserved across species. Identifying conserved interaction patterns provides a significant insight into the principles deriving evolution of cellular organizations and their functions .Network alignment is a computationally NP-hard problem owing to NP-completeness of the underlying subgraph isomorphism problem . Hence, The network alignment algorithms can also be classified into local and global network alignments based on the target region of interests. Global network alignment deals with aligning entire networks and finding the maximal set of mapped node pairs. Local network alignment, on the other hand, searches for highly similar sub-networks that likely represent conserved substructures. From a biological perspective, global network alignment seeks a comprehensive functional mapping of proteins between species while local network alignment identifies evolutionary conserved modules or protein complexes. Sometimes, local alignment is considered as many-to-many node mapping such that a node from one network can be aligned to multiple nodes from the other network, whereas global alignment as one-to-one node mapping with pairing all nodes from the smaller network. However, we have observed that some global alignment algorithms –7 producOne of the earliest global alignment algorithms IsoRank  estimatePathBLAST , one of In this paper, we propose a new pairwise local network alignment method called LePrimAlign - Local Entropy-based PageRank-inspired Markovian Alignment which uses graph-theoretic principles and the results of a many-to-many global network alignment algorithm to identify a set of conserved substructures between two PPI networks. To compare the performance of this approach with state-of-the-art local network alignment methods such as NetworkBLAST, AlignMCL and LocalAli, we have used the human, yeast and fruit-fly PPI networks in a genomic scale.The proposed pairwise local network alignment algorithm, LePrimAlign, properly integrates a powerful global alignment algorithm with the graph-theoretic concept and the optimization process of local alignment by cluster expansion to identify conserved modules. Figure Homo sapiens), yeast (Saccharomyces cerevisiae) and fruit fly (Drosophila melanogaster) were used to evaluate the proposed approach as they are well-explored. The up-to-date genome-scale PPI data have been downloaded from BioGRID , with 1 corresponding to perfect prediction. This measure makes a direct comparison between an output cluster and a known protein complex without any bias towards cluster size. For each output cluster, the best match to a protein complex was obtained in regard to its f-score. The average f-score of the best matches across all output clusters was used to determine accuracy of the local network alignment result.The Semantic similarity measures can quantify the functional similarity between genes or gene products by comparing the ontology terms that annotate them . Over thC1 and C2 of two different species. Then, the inter-species semantic similarity (ISS) between C1 and C2 is defined as:A pair of aligned clusters are expected to have similar functions as conserved modules and hence they are likely to have high semantic similarity. As a measure of alignment quality, we have used inter-species semantic similarity. Let us consider a pair of aligned clusters SS is the semantic similarity between proteins vi and vj, and |C1| and |C2| are the numbers of proteins in C1 and C2, respectively. The inter-species semantic similarity ranges in the interval , with 1 corresponding to the highest functional similarity.where Among a variety of semantic similarity measures, we have used simGIC  as it hae in one network that is directly aligned to an edge e′ in the other network where the two proteins linked by e have high sequence similarity  with the two proteins linked by e′, respectively. The larger number of conserved edges between aligned clusters indicates higher accuracy in predicting conserved modules. If an edge in one network is conserved with more than one edge in the other network, then they are counted as distinct conserved edges. The average number of conserved edges across all aligned cluster pairs was used to evaluate the alignment quality of local network alignment algorithms.A conserved edge (CE) is defined as an edge e in one network that is aligned to an edge e′ in the other network where the two proteins linked by e have high sequence similarity and high semantic similarity (SS) with the two proteins linked by e′, respectively. As the high semantic similarity condition, we have considered the simGIC scores greater than 0.2.We have also measured the average number of functionally consistent conserved edges for further evaluation of alignment quality. A functionally consistent conserved edge (F-CE) is defined as a conserved edge Additional file 1 Comprehensive evaluation results of LePrimAlign for human and yeast PPI network alignment. The proposed LePrimAlign algorithm has been implemented by changing the parameter values: the threshold θ and the scoring parameter γ. Complex prediction accuracy and alignment quality including inter-species semantic similarities (ISS), the average number of conserved edges (CE) and the average number of functionally consistent conserved edges (F-CE) are shown.Additional file 2 Comprehensive evaluation results of LePrimAlign for human and fruit Fly PPI network alignment. The proposed LePrimAlign algorithm has been implemented by changing the parameter values: the threshold θ and the scoring parameter γ. Complex prediction accuracy and alignment quality including inter-species semantic similarities (ISS), the average number of conserved edges (CE) and the average number of functionally consistent conserved edges (F-CE) are shown.Additional file 3 Comprehensive evaluation results of LePrimAlign for yeast and fruit Fly PPI network alignment. The proposed LePrimAlign algorithm has been implemented by changing the parameter values: the threshold θ and the scoring parameter γ. Complex prediction accuracy and alignment quality including inter-species semantic similarities (ISS), the average number of conserved edges (CE) and the average number of functionally consistent conserved edges (F-CE) are shown.


This study aimed to use graph theoretical analysis of anatomical covariance derived from structural MRI to reveal how the gray matter connectivity pattern is altered after corpus callosotomy (CC).We recruited 21 patients with epilepsy who had undergone CC. Enrollment criteria were applied: (1) no lesion identified on brain MRI; (2) no history of other brain surgery; and (3) age not younger than 3 years and not older than 18 years at preoperative MRI evaluation. The most common epilepsy syndrome was Lennox-Gastaut syndrome (11 patients). For voxel-based morphometry, the normalized gray matter images of pre-CC and post-CC patients were analyzed with SPM12 (voxel-level threshold of p<0.05 [familywise error-corrected]). Secondly, the images of both groups were subjected to graph theoretical analysis using the Graph Analysis Toolbox with SPM8. Each group was also compared with 32 age- and sex-matched control patients without brain diseases.Comparisons between the pre- and post-CC groups revealed a significant reduction in seizure frequency with no change in mean intelligence quotient/developmental quotient levels. There was no relationship among the three groups in global network metrics or in targeted attack. A regional comparison of betweenness centrality revealed decreased connectivity to and from the right middle cingulate gyri and medial side of the right superior frontal gyrus and a partial shift in the distribution of betweenness centrality hubs to the normal location. Significantly lower resilience to random failure was found after versus before CC and versus controls .Graph theoretical analysis of anatomical covariance derived from structural imaging revealed two neural network effects of resection associated with seizure reduction: the reappearance of a structural network comparable to that in healthy children and reduced connectivity along the median line, including the middle cingulate gyrus. Corpus callosotomy (CC) is an established palliative treatment for patients with intractable epilepsy who are not candidates for resective surgery. In a prospective population-based observational study, a greater than 50% seizure reduction was seen in 64% of the patients in the long-term follow-up, including 10% with seizure freedom .Total CC patients show a higher reduction in seizures than patients who undergo partial CC . Three fIt is largely unclear, however, why CC is effective for seizure and maladaptive behavior improvement and what kind of neural basis it alters. On the other hand, there were some effects of surgery in retrospective observational studies , 5, 6. BGraph theoretical analysis is a branch of mathematics whose central idea is to represent a complex set of relationships with a set of nodes and their connections . In the The present study aimed to reveal alterations in the structure of the neural network after CC. Graph theoretical analysis using structural MRI is a reasonable approach for a number of reasons. The first is that the corpus callosum is the largest white matter structure in the brain and the major commissural pathway connecting cortical regions of both hemispheres . The secIn this study, we applied graph theoretical analysis to the whole gray matter network. We clarified the postoperative network alterations in pediatric intractable epilepsy patients and compared the results with those of previous studies.From a total of 86 patients, 21 were selected in accordance with the following inclusion criterion: patients who underwent CC between 2010 and 2017 at the National Center Hospital, National Center for Neurology and Psychiatry (NCNP). The following enrollment criteria were applied: (1) no lesion identified on brain MRI; (2) no history of other brain surgery; and (3) age not younger than 3 years and not older than 18 years at preoperative MRI evaluation . The claIn addition, 32 age-matched patients with no central nervous system abnormality were recruited to comprise the control group in a conventional manner , 20. TheThis retrospective study was approved by the Institutional Review Board at the National Center of Neurology and Psychiatry (A2017-060), and the need for informed consent was waived.The framework of the analysis is the same as in Takeda et al.  and Sonehttp://www.neuro.uni-jena.de/cat/), which runs within SPM12. The morphological differences between the pre-CC and post-CC patient data groups were evaluated using the improved algorithms with CAT12 for longitudinal voxel-based morphometry analyses. The morphological differences between the pre-CC and control groups were also evaluated using CAT12 for cross-sectional analyses. These comparisons were performed with paired t-test analyses in SPM12. Differences meeting a voxel-level threshold of p<0.05 (FWE-corrected) and a cluster size criterion > 50 voxels were deemed significant.Subsequently, standard voxel-based morphometry was performed on the 3D T1-weighted MPRAGE images. Namely, the images were segmented into gray matter, white matter, and cerebrospinal fluid by a unified tissue segmentation procedure after image intensity nonuniformity correction. The segmented gray and white matter images were spatially normalized to a customized template in standardized anatomic space using Diffeomorphic Anatomical Registration through Exponentiated Lie (DARTEL) . Each imDmin–Dmax), where Dmin  means the lowest density that can permit a fully connected network /[L/Lrand], where Crand and Lrand, are the mean clustering coefficient and the characteristic path length of 20 random networks, respectively; and modularity, a measure of the strength of the division of a network into modules.The normalized gray matter images of each data group were submitted to graph theoretical analysis. For each group, the structural correlation network was constructed by analyzing a total of 90 cortical and subcortical regions of interest (ROIs) in the Automated Anatomical Labeling template  to form  network . Network network ). Additihttps://www.nitrc.org/prijects/gat/) with SPM8 running on MATLAB 2014a was used for the graph theoretical analysis in this study. The analysis is detailed elsewhere [In addition, the network resilience to random failure and to targeted attack was evaluated. Network resilience is associated with the stability of a complex network to acute and focal network damage . Random lsewhere .Comparisons were performed for the areas under the curve (AUCs) of each network measure and the resilience of the groups using GAT. To test the significance, the observed between-group difference in the AUC for each network measure was placed in the corresponding permutation distribution, and the p-value was calculated based on its percentile position. A one-tailed nonparametric permutation test (1000 repetitions) was performed for evaluation of the regional differences in BC and clustering between the two groups for each comparison. To correct for multiple comparisons, a false discovery rate p<0.05 was deemed significant.2 test for sex and seizure frequency, and paired t-test for antiepileptic drugs and IQ/DQ outcome with JMP 10 .For the clinical demographics, the differences in clinical parameters among the three groups were evaluated using one-way ANOVA for age at examination, Pearson’s χMean ages of the pre-CC, post-CC, and control groups were 8.5 (SD 4.2), 9.0 (SD 4.4), and 9.2 (SD 4.3) years, respectively. Sex  ratios of the CC and control groups were 11:10 and 13:19, respectively. There were no significant differences in the mean age and sex among the three groups . Participants’ postoperative outcomes are shown in Gray matter volume was not significantly changed between the pre-CC and post-CC groups and between the pre-CC and control groups.The results of network metrics are shown in The network nodes, edge locations, and the size of BC in the three groups are presented in This is the first study, to our knowledge, to focus on alterations in the anatomical covariance network after CC using 3D sagittal T1-weighted magnetization-prepared MRI. We performed graph theoretical analysis to evaluate differences in the anatomical covariance network between pre- and post-CC patients as well as in each CC group and the control group. The results suggested that post-CC patients had more common hub node locations with control children compared with pre-CC patients but decreased degree distribution and BC in the medial side of the superior frontal gyrus, decreased BC in the middle cingulate gyri, and lower resilience to random failure.No change in global network efficiency among the three groups was found in the present epilepsy patients. Previous studies taking graph theoretical approaches contrarily revealed an impaired anatomical covariance network affecting global networks in patients with generalized or focal epilepsy and stronger structural global connectivity and modularity with excessive network robustness versus controls , 19. FewWith respect to the effects of CC, the alteration in the BC distribution after CC was associated with the reappearance of normal hub nodes. Hub nodes in patients appeared after CC in the right rectus gyrus, and nodes marked by BC values 1 SD greater than the mean appeared in the left insula, fusiform gyrus, and parahippocampal gyrus. The BC-defined node locations in the patient group comprised a subset of the BC-defined nodes with values more than 1 SD in the control group see . We inteThe other effect of CC was a division of pathological paths. The values of both BC and degree distribution decreased postoperatively in the median line, although there was a discrepancy between the two metrics: while the BC was mainly reduced in the middle cingulate gyrus, the degree distribution was mainly reduced in the superior frontal gyrus. The lower median line after CC is consistent with the functional network results in patients with LGS in a 19-channel electroencephalography study , 9, in wThe altered structural and functional connectivity after surgery correlated with seizure frequency in the aforementioned articles. In our study, alteration of the anatomical covariance network after CC was associated with subsequent seizure reduction. In this vein, while the bilateral olfactory cortex remained the hub after CC, a hub in the bilateral rectus gyrus appeared postoperatively in place of the preoperative left superior frontal gyrus. Among the normal hubs observed in the control group, the left insula and left fusiform gyri appeared in the post-CC group. There may also be a relationship between the left parahippocampal hub in the post-CC group and the right parahippocampal hub in the control group. In addition, the interhemispheric connections to and from the right middle cingulate gyrus represented by BC seem to have been sloughed after dissection of the corpus callosum, although a hub was found there in the control group. This may mean that selective resection of the corpus callosum not only dissected the pathological path-propagated epileptic discharges, but also recovered the non-pathological hub node.There was no postoperative change in the gray matter volume of the thalamus and in the anatomical covariance between the thalamus and the cortex. A significant role of thalamocortical pathways was previously demonstrated in patients with LGS and other generalized epilepsies , 29, 30.Postoperative network-based anatomical covariance showed significantly lower resilience to random failure than the preoperative network and that of children without a central nervous system abnormality. The human brain network based on fMRI is characterized by having approximately the same resilience to random failure as random and scale-free networks and considerably greater resilience to targeted attack than the scale-free network . In anotThere are, however, several limitations to this study. First, the number of patients analyzed in the study was small. Second, the effect of CC was evaluated specifically in patients without a detectable lesion on MRI. There may be a difference in structural networks based on anatomical covariance in patients with a detectable MRI lesion. Third, all patients with epilepsy had been taking several kinds of antiepileptic drugs, which could have affected the results by altering brain function to various degrees. Patients prescribed carbamazepine and oxcarbazepine have lower BC in brain networks on graph theoretical analysis . Fourth,Despite these methodological limitations, the present study provides novel observations on epilepsy alterations in children after CC.Graph theoretical analysis of anatomical covariance derived from structural imaging revealed two structural network effects of CC related to a lower seizure frequency. One was a partial shift in the BC distribution to the normal location and the other was a reduced BC and degree distribution along the median line including the middle cingulate gyrus. The structural network showed significantly lower resilience to random failure after CC than before CC and compared with controls. Voxel-based morphometry did not reveal a significant effect of CC.S1 Fig(TIF)Click here for additional data file.S2 FigThe * marker (red) shows the difference between the pre-CC and post-CC networks. Any * markers (blue) overshooting the confidence intervals indicate densities at which the difference is significant. No trials were statistically significant.(TIF)Click here for additional data file.S3 FigThe * marker (red) shows the difference between control and the pre-CC networks. Any * markers (blue) overshooting the confidence intervals indicate densities at which the difference is significant. No trials were statistically significant.(TIF)Click here for additional data file.S4 FigThe * marker (red) shows the difference between control and the post-CC networks. Any * markers (blue) overshooting the confidence intervals indicate densities at which the difference is significant. No trials were statistically significant.(TIF)Click here for additional data file.S1 Appendix(ZIP)Click here for additional data file.S2 Appendix(ZIP)Click here for additional data file.S3 Appendix(ZIP)Click here for additional data file.S4 Appendix(ZIP)Click here for additional data file.S5 Appendix(ZIP)Click here for additional data file.S6 Appendix(ZIP)Click here for additional data file.S7 Appendix(ZIP)Click here for additional data file.S8 AppendixThe input data for the comparison between the pre-CC and control groups to CAT12.(ZIP)Click here for additional data file.S9 AppendixThe input data for the longitudinal comparison between the pre- and post-CC groups to CAT12.(ZIP)Click here for additional data file.


Cholesteryl Ester Transfer Protein (CETP) mediates the transfer of cholesteryl ester from HDL-C to LDL-C and VLDL-C. The aim of the present trial was to evaluate the effect of curcumin and its modified formulation on serum CETP concentrations in patients with metabolic syndrome. Participants were randomly allocated to one of three groups of 40 subjects receiving either unmodified curcumin or its phospholipid complex or placebo. Lipid profile and plasma CETP were measured at the start and six weeks after initiation of the treatment. The normality of data distribution was assessed by Kolmogorov-Smirnov test. Wilcoxon test was used for comparing the data before and after the intervention. The percent changes of CETP and biochemical factors among the three groups were compared using Kruskal-Wallis test.Serum CETP levels were not significantly altered among patients receiving curcumin.Curcumin and its complex had no significant effect on serum CETP concentrations. Metabolic syndrome is characterized by a cluster of metabolic abnormalities leading to an increased risk of cardiovascular diseases (CVD) and diabetes mellitus (DM) )Albert KGM et al.,2005 cholesterol, or low serum levels of high-density lipoprotein (HDL) cholesterol) is a common risk factor contributing to atherosclerosis )Chapman et al., 2011Curcuma longa  criteria. Exclusion criteria were pregnancy, lactation, systemic diseases including lupus and renal disorders as well as the use of cholesterol-lowering or other lipid-lowering drugs within the last 6 months. According to the changes in mean triglyceride before and after curcumin consumption among experimental and placebo groups, the sample size in each group was calculated as 35 subjects withtype one error 0.05 and power of 80%. Considering 15% dropout in samples, the sample size in each group was estimated as 40 subjects. Study designPatients referring to the dietetic clinic at Qaem Hospital were sequentially assigned to one of the treatment protocols by the researchers one after another; the curcumin group, and the curcumin phospholipid complex group taking 500 mg curcumin twice a day and a placebo group . PlaceboThe study protocol has been registered in the Iranian Registry of Clinical Trials (IRCT2014052014521N3)  and a stadiometer (0.1 cm accuracy). Patients were asked to stand without shoes with shoulders in contact with the wall. Waist circumference was measured at the midpoint between the last rib and the iliac crest while the hip circumference was measured at maximum hip circumference. Blood samples were obtained after 8-12 hr of fasting. After centrifugation, serum was separated and stored at - 80 ° C until analysis. Serum total cholesterol, LDL-Cholesterol, HDL-Cholesterol and triglyceride levels were measured by an auto-analyzer using commercial kits . Blood pressure (BP) was measured using Omron digital twice after 15 min rest in a sitting position.CETP measurementBefore and after the intervention, serum CETP levels were measured using a Human enzyme immunoassay Kit  and an ELISA Plate Reader device ,in accordance with the guidelines of the kit, respectively, the detection range was 0.78-50 ng/ml and the sensitivity was 0.2 ng/ml. All measurements were made in duplicate, and the intra-assay and inter-assay coefficients of variation were reported to be <8%and <10%, respectively. The precision and accuracy of all methods used in this study were checked using commercially prepared control sera . Statistical analysispost-hoc. Data were analyzed using SPSS version 16 software. A p-value<0.05 was considered statistically significant. Qualitative data including gender was compared among the three groups using Chi-square test. The normality of data distribution was assessed by Kolmogorov-Smirnov test. The non-normal data was compared using Wilcoxon (before and after intervention), one way ANOVA or Kruskal-Wallis tests (among groups). The percentage changes in CETP and biochemical factors among the three groups were compared using Kruskal-Wallis and a Bonferroni correction was made Baseline demographic, clinical and biochemical characteristics of the patients in three groups are illustrated in As shown in post-hoc tests showed that there were no significant differences in mean serum CETP concentrations between curcumin and complex curcumin groups (p=0.2), between curcumin and placebo groups (p=1) and between complex curcumin and placebo groups (p=0.9). The changes in the lipid profiles among different groups are also shown in Based on the results shown in Investigating the correlation between CETP changes and each of the clinical, anthropometric and biochemical factors, only indicated a significant negative correlation between serum HDL and CETP change among patients receiving complex curcumin . In addition, there were no significant interactions between CETP and biochemical factors on the effect of curcumin or modified curcumin .There is a close relationship between metabolic syndrome and risk of cardiovascular diseases  on CETP and lipid profile. Phosphatidylcholine complex of curcumin can enter the lipophilic cell membranes, thus increasing the bioavailability of curcumin. It has been proven that plasma concentration peak for phosphatidylcholine complex of curcumin, is five times higher than that of simple curcumin, in rats Shin et al. (2011)However, non- significant interactions between CETP and biochemical factors in this study, indicate that some changes observed in these factors are not in keeping with CETP changes. It might be in contrast to the hypothesis stating that the effects of curcumin on serum lipids are associated with CETP. CETP gene could decrease 50% of CETP protein and increase the HDL-C. In addition, inhibiting the CETP activity by statins administration leads to 5 to 15% increase in HDL-C concentration In conclusion, our study did not find evidence showing the effectiveness of curcumin in modification of serum CETP levels. Further studies are suggested to investigate these effects during longer periods.