A provegetarian food pattern (FP) was built by assigning positive scores to plant foods and reverse scores to animal foods. A healthful and an unhealthful provegetarian FP, which distinguished between healthy (fruits/vegetables/whole grains/nuts/legumes/olive oil/coffee) and less-healthy plant foods (fruit juices/potatoes/refined grains/pastries/sugary beverages), were also built. A total of 2320 new cases of overweight or obesity were identified after a median follow-up of 10.3 years. Higher baseline conformity with the overall provegetarian FP was inversely associated with overweight/obesity . This association was stronger for the healthful FP  and was not apparent for the unhealthful FP . In a large prospective cohort of relatively young adults, better conformity with a healthy provegetarian diet was associated with a reduced long-term risk of overweight/obesity, whereas no consistent trend was found for a FP that emphasized less-healthy plant foods.Provegetarian diets  have been associated with a reduced risk of long-term weight gain and could be more easily embraced than strict vegetarian diets. However, not all plant-derived foods are equally healthy. In the “Seguimiento Universidad de Navarra” (SUN) cohort, we prospectively evaluated the association between different provegetarian food patterns and the incidence of overweight/obesity in 11,554 participants with initial body mass index <25 kg/m It is well-established that diets higher in plant-based foods and with fewer animal source foods confer both health and environmental benefits ,2,3. PlaSince the potential mechanisms responsible for the beneficial effects of plant-based diets on body weight ,35,36,37The “Seguimiento Universidad de Navarra” (SUN) prospective cohort study started on December 1999 following the models of the Nurses’ Health Study and the Health Professionals Follow-Up Study. It is a multipurpose and dynamic cohort  composed of young middle-aged university graduates from different Spanish universities, including the University of Navarra. Baseline assessment and follow-up information is gathered through postal or web-based questionnaires completed by participants every 2 years. Self-administered questionnaires include information on sociodemographic, lifestyle and dietary variables as well as the use of medication and the prevalence or incidence of diseases during follow-up. For the main outcomes, medical records are requested to participants or their next of kin in order to confirm the diagnoses by a panel of medical doctors of the study, blinded to the dietary habits of participants and other exposures of interest. For participants lost to follow-up, the National Death Index is periodically checked to determine their vital status and cause of death. The overall retention in the cohort is higher than 90%. All procedures were approved by the Institutional Review Board of the University of Navarra (2017.151) according to Declaration of Helsinki guidelines. Voluntary completion of the baseline self-administrated questionnaire was considered to imply informed consent, as participants received detailed information about the study. Further details about the methodology and characteristics of participants have been described in more detail elsewhere .2) at baseline, 1628 who reported implausible values for total energy intake according to predefined limits , 95 women who were pregnant at baseline, 714 with prevalent chronic disease , and 393 with a weight change > 10 kg in the 5 years before entering the study to reduce the potential source of confounding by other causes of weight changes. Among the remaining 12,982 participants, 1160 were lost to follow-up leaving a total of 11,822 (retention = 91%). Additionally, we excluded 268 participants who had missing values in the variables of interest regarding the outcome. After exclusions, a sample of 11,554 participants was included in this study  ≥ 25 kg/mis study .A 136-item semi-quantitative food frequency questionnaire (FFQ) repeatedly validated in Spanish participants ,40 was cAdherence to an overall provegetarian FP was calculated according to the score proposed by Martínez-González et al. , which qLikewise, adherence to a healthful and unhealthful provegetarian FP was calculated according to the scoring criteria suggested by Satija et al. . HealthyAdherence to the Mediterranean diet was assessed using the a priori 9-item Mediterranean diet score (MDS) proposed by Trichopoulou et al. .The baseline questionnaire gathered information about sociodemographic and anthropometric characteristics, health-related habits, and clinical data including personal and family history of disease. Physical activity was assessed using a previously validated questionnaire, which included 17 different activities during leisure time . MetabolBaseline dietary intake data derived from food composition tables for Spain ,42 were 2); and (2) average change in body weight (grams) per year (g/y).Weight of participants was self-reported at baseline and every 2 years in the follow-up questionnaires. BMI was calculated as the self-reported weight in kilograms divided by the square of height in meters. Weight was self-reported by participants at baseline and every 2 years of follow-up. BMI was calculated as weight in kilograms divided by the square of height in meters, which was ascertained at baseline. Anthropometric data  have been previously validated in a subsample of this cohort finding strong correlation results . The outInverse probability weighting was used to determine the age- and sex-adjusted baseline characteristics of participants according to quintiles of adherence to the different provegetarian FPs in order to remove differences that were only explained by the different age and sex distribution across baseline quintiles of provegetarian FPs.2, continuous), physical activity , hours of TV watching (quartiles), smoking status , marital status , years of university education (continuous), total energy intake , snacking between meals , following a special diet at baseline , parental family history of obesity  and hours of siesta sleep . Robust standard errors were used. In order to reduce the effects of potential measurement errors due to diet variation during follow-up, dietary data were updated after 10 years of follow-up if the participant was followed for longer than 10 years and had completed the 10-year follow-up FFQ. Tests of linear trends were conducted using the medians of each provegetarian score for each quintile and treating the variable as continuous in Cox models. Moreover, to minimize the potential distortions produced by different measurement units in each provegetarian score, z scores were used. Each z score was calculated for each participant as the score value of the participant minus the mean value for the overall sample divided by the standard deviation of the score in the overall sample.Cox proportional hazards analyses were conducted to assess the relationship between provegetarian FPs with varying degree of healthfulness and the incidence of overweight/obesity. All models included age as underlying time variable and were stratified by age groups and year of recruitment. After crude analyses, a model adjusted for sex and age was fitted. Multivariable models were additionally adjusted for known risk factors of weight gain and potential confounders by using baseline values of the following covariates: Baseline BMI ) for the other four quintiles, which should be interpreted as the difference in average yearly weight change (g/y) for each of the upper four quintiles versus the lowest quintile. To take into account repeated measurements of diet, generalized estimating equations with an unstructured correlation matrix were used to assess the relationship between updated scores of the provegetarian FPs and average yearly weight change. Analyses were adjusted for the same confounding factors as the main Cox regression analysis.2 instead of BMI ≥ 25 kg/m2  in order to assess the incidence of obesity among overweight participants .Additional analyses were conducted after excluding participants with a baseline BMI ≥ 30 kg/m2 at baseline ; excluding early incident cases of overweight (participants who became overweight or obese only during the first 2 y of follow-up); additionally adjusting for weight gain ≥ 3 kg over the previous 5 years before entering the cohort; considering as the outcome only obesity (BMI ≥ 30 kg/m2) instead of overweight (BMI ≥ 25 kg/m2) and truncating follow-up at 10 years.Sensitivity analyses were conducted to explore the robustness of our findings by rerunning the analyses under the following scenarios: Excluding participants with energy intake between the 5th and 95th percentiles; excluding participants with no answer in > 12 items in the 136-item baseline FFQ; including participants with weight change > 10 kg over the previous 5 years before entering the study; excluding participants with BMI > 24.5 kg/mAll analyses were performed using STATA/SE version 12.0 .A total of 11,554 participants  were followed for a median of 10.3 years. Age-and sex-adjusted baseline characteristics of participants according to quintiles of adherence to the different provegetarian FPs are presented in 2) were identified. Hazard ratios (HR) and their 95% confidence intervals (CI) for the risk of overweight/obesity in the age-and sex-adjusted and multivariable-adjusted models are shown in Over 113,213 person-years of follow-up, a total of 2320 new cases of overweight/obesity  modestly decreased across quintiles of overall and healthful provegetarian FPs  and remained fairly constant across quintiles of the unhealthful provegetarian FP . The ave2) were identified. HRs and their 95% CIs for the risk of obesity in the age-and sex-adjusted and multivariable-adjusted models are shown in In an additional analysis conducted to assess the effect of several provegetarian FPs on incidence of obesity among overweight participants, a total of 669 new cases of obesity , we investigated the association between adherence to an unhealthful provegetarian FP exclusively composed of plant-based foods  and risk of overweight/obesity. We also explored the association between an unhealthful provegetarian FP composed of less-healthy plant foods (positively weighted) and animal foods (negatively weighted) and risk of overweight/obesity. The purpose of running these ancillary analyses was to study the independent effects of consuming more less-healthy plant foods compared to healthier plant foods  and compared to more animal foods .2) was the main outcome considered. Slightly stronger associations were found when participants with baseline BMI > 24.5 kg/m2 were excluded. The adverse association with the unhealthful provegetarian FP became stronger when the follow-up period was truncated at 10 years.Sensitivity analyses were conducted to assess the robustness of our results under a variety of scenarios . The ass2 , we found that a general preference for plant-derived foods (provegetarian FP) was modestly associated with lower risk of subsequently developing overweight/obesity during follow-up. This inverse association was considerably stronger when we specifically evaluated the preference for healthy plant-derived foods , whereas no such association was found for the preference for less healthy plant-derived foods . Our findings were robust in sensitivity analyses and remained consistent and significant when updating diet measurements with the use of repeated nutritional data obtained from the FFQ administered after 10 years of follow-up. Additional analyses including normal weight and overweight participants with an initial BMI < 30 kg/m2 revealed that we cannot be equally certain about the inverse association between these provegetarian food patterns and obesity among overweight subjects. These results are in line with recent findings from three ongoing prospective cohort studies in the United States, which were published while our paper was under review [In a Mediterranean dynamic prospective cohort study composed of university graduates with an initial BMI < 25 kg/mA-priori defined provegetarian indices were used to assess the effect of preference for plant-derived foods compared with preferential selection of foods from animal sources on the risk of new-onset overweight/obesity. This approach builds on previous research and includes well-defined food groups with varying nutritional content. Thus, results are in close agreement with previous findings, which could be expected, as most healthy plant foods positively weighed in the healthful provegetarian FP  have been consistently associated with lower risk of weight gain. Likewise, less-healthy plant foods positively weighed in the unhealthful provegetarian FP  have been consistently associated with higher risk of weight gain . NoteworThe associations observed between a general preference for plant-derived foods and lower risk of overweight/obesity are consistent with previous research ,18,19,20The potential mechanisms underlying our findings may be related to the preventive effect against overweight/obesity of a high intake of foods containing dietary fiber and bioactive compounds, which are naturally found in fruits and vegetables. Minimally processed plant-based foods are typically low in energy density and contain high concentrations of micronutrients and phytochemicals like flavonoids that may have a beneficial influence on energy homeostatic pathways . Other cBeyond the health of individuals, and taking into consideration the health of our planet, it is also known that the adoption of provegetarian food patterns could significantly reduce greenhouse gas emissions  as well 2, which minimized the possibility of reverse causation bias; and the use of repeated measurements of the diet, which reduced potential measurement errors and increase validity of well-validated self-reported comprehensive food-frequency methods such as the SUN cohort FFQ that has been repeatedly validated in Spanish participants [The strengths of the present study include the prospective longitudinal design with a long follow-up period and a relatively large sample size; the restriction to participants with baseline BMI < 25 kg/micipants ,37.The present study also has some limitations. Although we adjusted for a wide array of potential confounders, we cannot exclude the possibility of residual confounding given the observational nature of the study design and the fact that adherence to the overall and healthful provegetarian was higher among participants with healthier characteristics . However, the restriction to highly educated participants was applied to control for confounding by socioeconomic status, which is an approach considered in epidemiology as an excellent technique to reduce confounding . This alIn conclusion, higher adherence to a provegetarian FP emphasizing preference for healthy plant-derived foods was associated with a lower risk of developing overweight and obesity in a cohort of Spanish university graduates with initial low body mass index. Given that excess weight is also a critical risk factor for developing other increasingly frequent non-communicable chronic diseases, a generalized adoption of healthful provegetarian diets is an important target that should be considered in future public health policies.


N- and O-linked glycans on well-established expression systems remains challenging. On the one side the glycosylation machinery in mammalian cells is hard to control due to its complexity. Most bacteria, on the other side, completely lack such glycan formations, and in general exhibit fundamental differences in their glycosylation abilities. Beyond that, plants generate complex N-glycans typical of higher eukaryotes, but simpler than those produced by mammals. Paradoxically, it seems that the limited glycosylation capacity of plant cells is an advantage for specific glycan manipulations. This review focuses on recent achievements in plant glycan engineering and provides a short outlook on how new developments (in synthetic biology) might have a positive impact.With respect to biomanufacturing, glycosylation is one of the most addressed post-translational modifications, since it is well-known that the attachment of sugar residues efficiently affects protein homogeneity and functionality. Much effort has been taken into engineering various expression systems to control glycosylation and to generate molecules with targeted sugar profiles. Nevertheless, engineering of  Solanaceous species within the genus Nicotiana, specifically Nicotiana tabacum (tobacco) and Nicotiana benthamiana , are currently considered the most appropriate hosts in Molecular Farming. Advantageous features include (i) ease of cultivation and high biomass; (ii) availability of genetic tools for trait manipulation; (iii) amenability to new plant breeding techniques (CRISPR/Cas9); and (iv) non-food status, which minimizes the possibility of contamination of the food supply with industrial designated products.Plant-based biomanufacturing of (therapeutic) proteins is a relatively new approach with a small number of commercial-scale facilities, although a techno-economic analysis of plant-based platforms estimated a >50% reduction of capital investment and cost of goods compared to mammalian cell expression systems . This review concentrates on the ability of plants to produce proteins with targeted glycosylation profiles. A special interest is the generation of targeted human glycoforms at large homogeneity, as this can hardly be achieved by mammalian expression hosts due to their complex endogenous glycosylation machinery. This is of particular interest for the biopharmaceutical industry, since the majority of therapeutic proteins are glycosylated and it is well known that the glycan profiles have a significant impact on protein stability and functionality. In fact, it has been shown that certain protein functionalities can be reversed, depending on the glycosylation profile. Impressive examples are IgG antibodies that exhibit pro or anti-inflammatory activities, depending on their glycosylation profile  with intricate post-translational modifications  are GnGnXF structures, a complex N-glycan formation carrying β1,2-linked xylose and α1,3-linked fucose residues attached to the GlcNAc2Man3GlcNAc2 (GnGn) core   structures [(FA)(FA)XF] are frequently detected in the plant kingdom  elimination of plant specific residues , (ii) ablation of HEXO activities, and (iii) elimination of Lea structures. Pioneering work in plant glycoengineering focused on the elimination of the genes that encode β1,2-xylosyl- and core α1,3- fucosyltransferases. Three approaches were successfully applied: genomic mutational knockout, genome editing and gene silencing (sense and antisense RNAi). These resulted in a number of plants and plant cell cultures that indeed synthesize GnGn structures (lacking xylose and fucose residues) at large homogeneity  plants, which were used as experimental drug during the last viral outbreak in East Africa 2014–2015 . Some proteins (endogenous and recombinantly produced) carry exclusively MMXF structures for reasons that are not yet understood  are detected in various plant species  activity. GnTI is a key enzyme in the processing of Man5 structures to complex N-glycans, so a GnTI-deficient (cgl) Arabidopsis mutant accumulates Man5 structures  generate the central acceptor substrate for further elongation/diversification steps, and (iii) increase glycan homogeneity. The latter has substantial implications for downstream processing and meet important regulatory requirements for therapeutic proteins. Notably, there is an ongoing debate on whether plant-specific xylose and fucose residues that are not present in mammals can be tolerated on recombinant therapeutic proteins and whether they present an increased risk for adverse side reactions  have improved biological activities .Collectively, these knockout/knockdown approaches are milestones in plant glycoengineering because they (i) demonstrate the ability of plants to tolerate manipulations of the N-glycans that is conserved up to the generation of GnGn structures. With a few exceptions , plants do not accomplish further diversification of N-glycans because they lack the necessary enzymatic catalog. Nevertheless, it seems that plants are equipped with the molecular requirements for mammalian/human-type glycan processing. Approaches to augment plant glycosylation toward human structures are mainly based on the recombinant expression of human glycosylation enzymes  in plants. This is showcased by the generation of bisected (GnGnbi), branched ([GnGn][GnGn]), and galactosylated (AA) N-glycans, which are frequently found on human proteins, but are absent in plants , reaching a degree of polymerization of up to 400  to serine or threonine residues (mucin-type O-glycosylation). Usually, these GalNAc residues are further modified by the stepwise addition of different monosaccharides , giving rise to diverse mucin-type core O-glycan structures that play crucial roles in many different biological processes  in Arabidopsis, tobacco BY2 cells and N. benthamiana . This GalNAc residue serves as a substrate for subsequent elongation with β1,3-galactose by overexpressing β1,3-galactosyltransferase  , only a few sites are modified when several sites exist, as shown for the hinge region of human IgA1  and of a UDP-GalNAc transporter yields a more efficient initiation of O-glycosylation . The therapeutic potential of such glycoproteins for the treatment of allergies and autoimmune diseases is anticipated, which increases the interest in their controlled reconstruction. Recent studies exploit plant glycosylation to produce such helminth glycoforms. Overexpression of specific glycosyltransferases  in N. benthamiana enabled the reconstruction of Lewis X and LDN-motives  or in the discovery of new glycan-associated functions. A good example of the latter is the discovery of the multiple functions of polySia in immunological and neurological settings  proteins like antibodies can be specifically modulated and improved. The augmentation of the endogenous glycosylation repertoire by overexpressing foreign glycosylation enzymes (mostly transferases) has led to the production of defined complex Both authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Thixotropy is one of the oldest documented rheological phenomenon in colloid science and may be defined as an increase of viscosity in a state of rest and a decrease of viscosity when submitted to a constant shearing stress. This behavior has been exploited in recent years to prepare injectable hydrogels for application in drug delivery systems. Thixotropic hydrogels may be profitably used in the field of regenerative medicine, which promotes tissue healing after injuries and diseases, as the molten hydrogel may be injected by syringe and then self-adapts in the space inside the injection site and recovers the solid form. We will focus our attention on the preparation, properties, and some applications of biocompatible thixotropic hydrogels. Thixotropy is one of the oldest documented rheological phenomena in colloid science . Althoug2O3 is shaken, but a sol-gel transition occurs if the mixture is allowed to rest. After that, a lot of other materials displaying a similar behavior were discovered, so rheology became a distinct discipline and a definition of thixotropy was coined: “The application of a finite shear to a system after a long rest may result in a decrease of the viscosity or the consistency. If the original viscosity or consistency is recovered, this behavior is called thixotropy” by IUPAC.This phenomenon was described for the first time in 1923 by Schalek and Szegvari  formed gels (l-lysine (Fmoc-K) failed under similar experimental conditions. The second Fmoc-moiety provides a lead to construct or design new synthetic Fmoc-based LMW organogelators and/or hydrogelators . It. Itl-lys systems ,49.N-protecting groups  moiety and selected amino acids were used as low molecular weight gelators (LMWGs) to prepare strong and thixotropic hydrogels at a physiological pH  becomes obvious. The peptide nature of hydrogels ensures the biocompatibility, hence the possibility to encapsulate various types of cells inside the gel matrix, emulating the three-dimensional environment where cells are used to grow. Jain et al. make use of poly-ilicates  to form p-hydroxybenzylalcohol to peptide bolaamphiphiles . Th. Th80]. Wu et al. reported the preparation of a silk nanofiber-based hydrogel and its use to deliver doxorubicin for localized chemotherapy in breast cancer  81]. Th. Th81]. Silk-based thixotropic hydrogels incorporating hydroxyapatite (HA)  show ostTo harvest silk fibroin- (SF) based organic/inorganic composites with various general properties  and to produce a film or a hydrogel of SF-nanofibril/nanohydroxyapatite, Shao et al. employed the strategies of vacuum filtration and centrifugation  83]. SF. SF83]. Thixotropy is one of the oldest documented rheological phenomena in colloid science. Although the phenomenon is very common in industrial and natural systems, a general rheological model capable of fully describing the different features of thixotropy has not yet been developed and there even remains some confusion about its definition.Stimuli-responsive materials showing thixotropic properties in response to external environmental stimuli have attracted considerable attention due to their wide ranges of potential applications in biomaterials, sensors, displays, surface science, etc.The use of low molecular weight gelators (LMWGs) may lead to the formation of thixotropic supramolecular hydrogels, which are physically cross-linked three-dimensional networks with solvent molecules entrapped inside through noncovalent intermolecular interactions such as H bonding and π−π stacking.Supramolecular thixotropic hydrogels may be used in a range of biological applications, including drug delivery, tissue engineering, and cell culture. Regenerative medicine is a field of increasing interest as it promotes tissue healing after injuries and diseases. Tissue engineering involves the use of biomaterial scaffolds to create in vitro three-dimensional tissue-like structures that simulate the extracellular matrix (ECM) where cells can grow, as typical bi-dimensional cell cultures often lack the ability to effectively simulate the physiological environment. As hydrogels are mainly constituted of water (>95%), they have been extensively studied as materials for the culture and encapsulation of cells and may be injected to act locally in the specific region being treated, avoiding surgical procedures. The thixotropic behaviour extends the range of hydrogel applications, as it can be easily transferred through a syringe and locally injected.


HIV-testing coverage remains below the targeted 90% despite efforts and resources invested. Home-based HIV-testing is a key approach endorsed by the World Health Organization (WHO), especially to reach individuals who might not seek testing otherwise. Although acceptance of testing during such campaigns is high, coverage remains low due to absent household members. This cluster-randomized trial aims to assess increase in testing coverage using oral HIV self-testing (HIVST) among individuals who are absent or decline testing during home-based HIV-testing.The HOSENG (HOme-based SElf-testiNG) trial is a cluster-randomized, parallel-group, superiority trial in two districts of Lesotho, Southern Africa. Clusters are stratified by district, village size, and village access to the nearest health facility. Cluster eligibility criteria include: village is in catchment area of one of the study facilities, village authority provides consent, and village has a registered, capable, and consenting village health worker (VHW). In intervention clusters, HIV self-tests are provided for eligible household members who are absent or decline HIV-testing in the presence of the campaign team. In control clusters, standard of care for absent and refusing individuals applies, i.e., referral to a health facility. The primary outcome is HIV-testing coverage among individuals aged 12 years or older within 120 days after enrollment. Secondary objectives include HIV-testing coverage among other age groups, and uptake of the different testing modalities. Statistical analyses will be conducted and reported in line with CONSORT guidelines. The HOSENG trial is linked to the VIBRA (Village-Based Refill of ART) trial. Together, they constitute the GET ON (GETting tOwards Ninety) research project.The HOSENG trial tests whether oral HIVST may be an add-on during door-to-door testing campaigns towards achieving optimal testing coverage. The provision of oral self-test kits, followed up by VHWs, requires little additional human resources, finances and logistics. If cost-effective, this approach should inform home-based HIV-testing policies not only in Lesotho, but in similar high-prevalence settings.NCT03598686). Registered on 25 July 2018. More information is available at www.getonproject.wordpress.com.ClinicalTrials.gov, (ID: The online version of this article (10.1186/s13063-019-3469-2) contains supplementary material, which is available to authorized users. The United Nations Programme on HIV/AIDS (UNAIDS) has shown a way forward in controlling and finally ending the deadly acquired immune deficiency syndrome (AIDS) epidemic by launching the 90-90-90 strategy . The firHIV self-testing (HIVST) has proved to be an accurate diagnostic tool that increases uptake of HIV-testing, facilitates linkage to care among target populations, and may be more cost-effective than provider-delivered HIV-testing –17. ThusHowever, to date only limited data are available, assessing the effect of oral HIVST in increasing HIV-testing coverage. This randomized controlled trial thus aims to determine the added effect of distributing oral HIVST to individuals absent or refusing to test during a home-based HIV-testing campaign on HIV-testing coverage.2. According to the recent household-based national survey from 2016 to 2017 the adult HIV prevalence is 17.8% in Butha-Buthe and 26.1% in Mokhotlong [The HOSENG (HOme-based SElf-testiNG) trial will be conducted in the districts of Butha-Buthe and Mokhotlong, in Northern Lesotho, Southern Africa, in the catchment areas of 22 health facilities. Both districts are characterized by mostly rural settings with an estimated population of 220,000, mainly subsistence farmers and mine workers as well as construction or domestic laborers who work in neighboring South Africa. Each district has only one mid-size town: Butha-Buthe with approximately 25,000 inhabitants, and Mokhotlong with approximately 10,000 inhabitants. The remaining population lives in villages scattered over a mountainous area of 5842 kmkhotlong .The HOSENG trial is a cluster-randomized controlled, superiority trial in a resource-limited setting. The rationale for a cluster-randomized design at village level is (1) the reliance of the trial on the village health workers (VHWs) and (2) the high risk of cross-contamination between the study arms if randomization would be done at the individual or household level. The HOSENG trial, with its home-based HIV-testing campaign, provides a recruitment platform for another trial, the VIBRA (Village-Based Refill of ART) trial , and thuFigure Table Before randomization, all VHWs from the 180 randomly selected villages attend a 1-day refresher training focusing on HIV-testing and counseling (HTC). Every VHW takes a short pre- and post-training assessment. The assessment includes questions about (1) HIV knowledge and HIV stigma using a validated questionnaire , (2) HIVPrior to trial start, the research team met with all relevant village chief councils in order to inform them about the trial and to obtain their consent.The counselor will introduce him- or herself and explain the purpose of the testing/screening campaignIf the head of household or the representative refuses their household participation, the team will leave the house, record the refusal reason, and proceed to the next householdThe counselor will ask the head of household or their representative (aged 18 years and older) for written informed consent to the testing/screening campaign, and to obtaining data about present and absent household members for study purposeDefinition of household member: (1) is acknowledged by the household head or the representative as part of the household and (2) sleeps in the household regularly (at least once a month), and (3) if absent during the campaign: returns to the household no later than 3 months after the date of the home visitThe counselor will assess the total number of present and absent household membersThe counselor will provide information about HIV and testing, prevention aspects, and the other disease screenings (see below)bukana”)The counselor will assess the HIV status of all household members and screen the patient’s health booklets Fig. 2HIHousehold members who are eligible for and consent to testing  undergo HIV-testing by the counselor according to specific cluster-arm allocation procedure and according to national HIV-testing guidelines . For absTwo to three specifically trained teams, each consisting of five to six lay-counselors, one campaign organizer and one supervising study nurse will visit all households in selected villages, going from door to door. The teams will propose HTC and multi-disease screenings and prevention. The population of the selected areas are informed about the campaign beforehand by their village chief. Specifically, the campaign team will arrive in the village in the morning, meet with the village chief and then start systematically visiting all households in the pre-defined area by going from door to door. At the household, the teams will proceed as follows:The HIV-testing campaign is combined with additional multi-disease screening. The campaign screens for tuberculosis (TB) according to national guidelines using the clinical symptom screening tool . If TB iFigure One household member – the one with the closest relation to the absent person(s) – will be tested and trained using the oral HIVST. All other present household members will be tested using the standard blood-based point-of-care HIV test according to Lesotho national guidelines .The VHWs in the intervention custers will receive a list of all household members for whom an oral HIVST was dispensed. The VHW will visit all households 2–4 weeks after the campaign to collect the oral HIVST in case the oral HIVST is not returned to the VHW. If an oral HIVST is reactive, the VHW will either provide further blood-based testing on the spot or organize referral to the nearby health facility for confirmatory testing. All VHWs from intervention clusters will receive a second extensive training session about oral HIVST, handling disclosure and stigma, and data entering on paper-based study forms and the patient’s health booklet.Following standard of care during home-based HIV-testing, every absent household member or those declining HIV-testing will be encouraged to get an HIV test done by the VHW or the nearby health facility. The research team will screen the registers at the health facilities in order to assess if these individuals came for testing in the timeframe of the primary endpoint window.The primary endpoint is HIV-testing coverage among individuals aged 12 years or older in the surveyed area within 120 days after the home visit, defined as the proportion of all individuals aged 12 years or older living in a household of the surveyed area with a confirmed HIV test result.We define a confirmed HIV-negative result as either being tested HIV-negative as per the algorithm defined in Fig. The rationale for the time point of 120 days is that we leave oral HIVST kits at the households for all absent household members aged 12 years or older who return within a maximum of 3 months , conducted in the local language (Sesotho). Qualitative data will be recorded, transcribed, translated into English and coded and analyzed using the Framework Method [A nested study  will explore the effectiveness acceptability of oral HIVST among adolescents and young adults with quantitative methods  and qualitative methods (case-control study). Cases are those who refused testing through oral HIVST and controls are those who accepted testing through oral HIVST. We plan to conduct at least 10 interviews per group, stratified by two pre-defined factors , following the concept of saturation. Data will be collected by a trained study member, who was part of the HIV-testing campaign, using a piloted interview questionnaire . The randomization assignment of the villages is pre-loaded into the program and a unique household identifier is automatically generated. Before leaving the household, the completed questionnaire will be checked for mistakes and completeness. Data from the tablet devices will be uploaded regularly via secure electronic transfer and stored on a secure server at the Swiss Tropical and Public Health Institute (Swiss TPH). After the follow-up period, all confidential information of the study participants  will be deleted from the database and only the anonymous study ID will be kept. The informed consent forms will be stored in a secure way in the headquarter of the study center . Participant files will be maintained in storage for a period of at least 10 years after completion of the trial.The VHWs enter data for following up the dispensed oral HIVST kits on standardized paper study forms (case report forms) that act as source documents. These data will be collected regularly by the study team and entered into the above-mentioned platform. A study data manager will monitor data quality and completeness on a weekly basis. Queries about the data will be sent to the local principal investigators for follow-up and correction, as needed. Data integrity checks will be written into the database to limit missing fields or the entry of incorrect data. The type of activity that an individual user in the online study database may undertake will be regulated by the privileges associated with their user identification code and password.The sample size is driven by the VIBRA trial . We assuAnalyses will be reported following Consolidated Standards of Reporting Trials (CONSORT) guidelines for cluster-randomized trials . Clusterp values with an alpha = 0.05 level of significance.Baseline characteristics will be presented according to randomized groups; no formal testing will be performed. Categorical variables will be described with absolute and relative frequencies and continuous variables with medians and interquartile ranges. As with the primary analysis, secondary endpoints will be analyzed with multi-level logistic regression models including village and household as random effects. All results will be presented as odds ratios and 95% confidence intervals. The potential effect modification of sociodemographic determinants  on all endpoints will be assessed by including interaction terms in the models. If the Wald test results for the interaction terms are significant, intervention effects will be presented separately by the levels of these factors. Sensitivity analyses will be conducted in order to provide evidence that the result seen from the primary analysis are robust. In order to assess the reliability of the model fit, we will perform a quadrature check. In case of unreliable model fit, we will use generalized estimating equations to fit our model which will provide population-averaged odds ratios and 95% confidence intervals. However, this model would not allow inclusion of more than one random effect although including the highest level of clustering is suggested to be sufficient . All anaAt least one external monitoring visit will assess adherence to the approved trial protocol, accuracy of completed study forms, and the electronic dataset. The principal investigator agrees to allow inspectors from regulatory agencies to review records and will assist the inspectors in their duties, if requested.The HOSENG trial represents implementation research and the oral HIVST is a well-established diagnostic tool. Thus, we do not expect serious adverse effects (SAE) on patients’ health from this intervention. However, for the purpose of this trial, we will try to capture the following SAEs: (1) Death due to any reason , (2) Hospitalisation due to self-inflicted injuries within 30 days of a positive HIVST results, and (3) Hospitalisation resulting from violent assault by others  within 30 days of a positive HIVST result. The campaign team members all have several years of experience in HTC and received an additional study-specific, 1-week training in order to handle adverse events related to testing stigma. A separate, detailed safety monitoring plan will be developed to handle these SAEs in line with Swiss and Basotho ethics regulations. It is not planned to establish a data safety and monitoring board.HIV-testing constitutes the “front door” to reach the UNAIDS 90-90-90 targets . CurrentHome-based HIV-testing campaigns have been shown to be very effective in achieving high testing uptake, especially in resource-limited countries . HoweverThe trial has been launched on 26 July 2018 in both study districts. The recruitment time is driven by the VIBRA trial , as the Additional file 1: Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Checklist: recommended items to address in a clinical trial protocol and related documents*. (PDF 82 kb)


Polariscopy is demonstrated using hyperspectral imaging with a focal plane array (FPA) detector in the infrared (IR) spectral region under illumination by thermal and synchrotron light sources. FPA Fourier-transform IR (FTIR) imaging microspectroscopy is useful for monitoring real time changes at specific absorption bands when combined with a high brightness synchrotron source. In this study, several types of samples with unique structural motifs were selected and used for assessing the capability of polariscopy under this FPA-FTIR imaging technique. It was shown that the time required for polariscopy at IR wavelengths can be substantially reduced by the FPA-FTIR imaging approach. By using natural and laser fabricated polymers with sub-wavelength features, alignment of absorbing molecular dipoles and higher order patterns (laser fabricated structures) were revealed. Spectral polariscopy at the absorption peaks can reveal the orientation of sub-wavelength patterns  or the orientation of the absorbing dipoles. For the spectral mapping of processes and material modifications in real time, data acquisition with a focal plane array (FPA) becomes a prerequisite in infrared (IR) microspectroscopy. This is particularly important for spectral characterisation of materials using Fourier transform IR (FTIR) microspectroscopic systems at synchrotron facilities where the extracted IR beam possesses the highest brightness . PolarisTM) source and synchrotron radiation  for the transmitted light intensity d is the thickness of the sample, transmittance c is the speed. Imaging resolution of the FTIR microscopes used were close to the diffraction limit and was specially tested for the synchrotron radiation [The absorbance or optical density Three samples with sub-wavelength features, including (i) a circular metal grating, (ii) a laser-polymerised radial structure, and (iii) natural brown silk, were used for FPA-FTIR microspectroscopic imaging measurements.TM) source. The reference sample was a circle with sub-wavelength grooves with a period of 200 nm and half-pitch spacing of 100 nm. The grating was milled with a focused ion beam  through a 100-nm-thick Au sputtered film, using thin sapphire as a substrate (T at 3000 cm−1 (T) was observed in the locations where The first FPA-FTIR experiments were carried out using a thermal IR , 1716 cm−1 (due to the C=O stretching of carbonyl), and 2700 cm−1 (where there was no specific absorbance in the SZ2080) were selected for the orientation mapping. The Q-plate was polymerised using circularly polarised light at Q-plate  grating a. The po writing .−1, the determined alignment was due to the structure of the q-plate rather than the molecular alignment within the polymer. Pixel dimensions (2) are larger than those of the −1 (aw cos2θ . The resAntheraea pernyi) was investigated after a standard degumming procedure, which provided single strands [Brown silk produced by wild moth  or that of the structural pattern that is not spatially resolved (q-plates), or the polarisation of the transmitted light (circular nano-grating), was revealed in the azimuthal orientation images obtained at four orientations of the linearly polarised light. The pixel dimensions were smaller than the diffraction limit in all cases. Well-defined radial orientation of the grooves was recovered by the applied four-angle method. We discuss the application of such a grating as a polariser for the four-angle method. In laser-polymerised, azimuthally orientated gratings—the q-plates—the radial pattern was also reliably retrieved in the orientation images. The highest spatial frequency of molecular absorbers was in brown silk, and the orientational azimuth was reliably determined. In addition to the uniform illumination using a thermal-IR source, we also used focused synchrotron-IR irradiation at higher magnification, and the same orientation of the absorption bands in silk was confirmed.It has been shown that the orientation of dipoles, which are sub-1 nm objects and absorb in the IR spectral window, was determined by polariscopic imaging. The alignment and secondary structure of al range . Additioal range ,27 can b


Self-harm and depression are strong risk factors for repeat self-harm and suicide. We aimed to investigate the feasibility of a randomised controlled trial (RCT) of remotely delivered problem-solving cognitive behaviour therapy (PSCBT) plus treatment as usual (TAU) versus TAU in young people with repeat self-harm and depression.Single-blind multi-centre RCT with an internal pilot, pre-set stop-go criteria and qualitative semi-structured interviews. Eligible participants (aged 16–30 years) were recruited from 9 adult or child and adolescent self-harm and crisis services; had ≥ 2 lifetime self-harm episodes, one in the preceding 96 h; and Beck Depression Inventory-II (BDI-II) score ≥ 17. Participants were randomised (1:1) to either TAU or TAU and 10–12 sessions of PSCBT delivered by mobile phone or video-calling.Twenty-two participants were recruited (11 in each arm), 10 (46%) completed follow-up at 6 months, 9 (82%) started the PSCBT and 4 (36%) completed it. The study did not meet three of its four stop-go criteria, reflecting considerable barriers to recruitment and retention. Participants had severe depression symptoms: with mean BDI-II 38.9 in the PSCBT and 37.2 in TAU groups, respectively. Three (14%) unblindings occurred for immediate safety concerns. Barriers to recruitment and retention included lack of agency for participants, severity of depression, recency of crisis with burden for participants and clinicians who diagnosed depression according to pervasiveness.RCTs of PSCBT for young people with depression and self-harm are not feasible using recruitment through mental health services that conduct assessments following self-harm presentations. Clinician assessment following self-harm presentation mainly identifies those with severe rather than mild-moderate depression.ClinicalTrials.gov (NCT02377011); Date of registration: March 3rd 2015. Retrospectively registered: within 21 days of recruitment of the first participant.The online version of this article (10.1186/s12888-018-2005-3) contains supplementary material, which is available to authorized users. There are strong associations between self-harm and depressed mood and both are significant risk factors for suicide –4. Of thThe main aim of this study was to determine the acceptability and feasibility of carrying out an RCT of remotely delivered  problem-solving cognitive behaviour therapy (PSCBT) plus treatment as usual (TAU) versus TAU in adolescents and young adults with depression who self-harm. Before the study started, as recommended in the Cochrane systematic review of interventions for self-harm for children and adolescents , we invoGroup 1 received treatment as usual (TAU). Participants did not receive any additional treatment to what was routinely offered.Group 2 received TAU and 10–12 sessions of problem-solving using cognitive behaviour therapy (PSCBT) provided by a trained therapist. The PSCBT was delivered by mobile phone or video-calling, depending on the participant’s preference.The e-DASH (electronic - Depression and Self-Harm) study was a parallel group single-blind multi-centre RCT, exploring feasibility and acceptability, using quantitative and qualitative methodologies .A score of 17 or more, indicating at least the higher end of mild depression symptoms, on the Beck Depression Inventory version 2 (BDI-II)  so that Ability to take part in psychological therapy in English.Ability to give informed consent.Clinical judgement of high level of suicide risk, other risk to self or others requiring urgent approaches e.g. psychiatric admission.Severe mental disorder  as the primary mental health problem, as determined by a structured psychiatric interview - the Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID) .Currently receiving structured psychological therapy.ClinicalTrials.gov (NCT02377011).Participants were recruited from 13th February 2015 to 22nd April 2016, in the East Midlands region of England, through: 1) adult or child and adolescent mental health services that assess people in emergency rooms or hospital wards following a self-harm presentation; 2) adult or child and adolescent community mental health services that see people with depression and self-harm; 3) a third sector organisation providing interventions and support to people who have self-harmed. In keeping with the Clinical Trials recommendation, the trial was registered within 21 days of recruitment of the first participant. Trial registration: The procedure of recruitment followed the successful approach described by Brown et al. , except To compensate participants for their time they were given a shopping voucher following the completion of the baseline assessments. Participants who remained in the study until the end (6 months) received another voucher to thank them for taking part. Similarly, study participants completing the qualitative interview (see below) were offered a voucher as an inconvenience allowance for their participation. Travel expenses were offered for any visits incurred as a result of research participation.https://www.webex.com) according to participant preference. Once randomised to the intervention arm of the study, participants (according to their preference expressed at recruitment) received a text message, email or telephone call from the study therapist inviting them to participate in a 1 hour pre-therapy session  as well as external problems (e.g. relationships) for people who had self-harmed , 22. TheThe primary outcome measure was the self-rated Beck Depression Inventory-II (BDI-II) ; a score9 item Personal Health Questionnaire (PHQ-9) measuring depression Beck Hopelessness Scale Generalised Anxiety Disorder Assessment (the GAD-7) Columbia Suicide Severity Rating Scale (CSSRS) to assess suicidality Work and Social Adjustment Scale (WSAS) EQ-5D 5 L as a measure of health utility Secondary outcome measures were the:In addition, the 12-item Urgency Perseverance Premeditation Sensation-seeking (UPPS) Impulsive Inventory urgency subscale was used at baseline to measure trait ability to resist impulses to behave irresponsibly in response to negative emotions such as depression, anxiety, or anger . In the Consenting participants’ details were entered onto a web-based randomisation system which was password-protected and conducted through a registered Clinical Trials Unit . This generated an email containing details of group allocation which was sent to the trial co-ordinator or administrator who then sent details of the allocation to the CBT therapist. The researcher, blinded to randomisation, only received an email stating that the participant had been randomised. Participants in the study were randomly allocated to either the intervention group (PSCBT plus TAU) or TAU only. Participants were allocated with equal probability to each treatment arm with stratification by NHS Trust or third sector organisation. The participant was assigned to treatment by a computer-generated pseudo-random code using random permuted blocks of varying sizes of two, four or six, created by the Nottingham CTU in accordance with their standard operating procedure and held on a secure server. Only the trial co-ordinator, or their nominee, had password access to the randomisation data. All unblindings were recorded.Based on the Slee et al. study , with BDRecruitment of 5 participants per month;Collection of data from 70% participants on primary outcome at 6 months;Engagement of 80% participants allocated to the PSCBT intervention;Retention of 60% participants for 10–12 sessions of the PSCBT intervention.The following criteria were set before the study started to indicate that both the study and intervention were feasible for a full RCT:A detailed log was collected on all attempts by the research team  research staff who were blinded to the intervention arm) and 0.4wte CBT therapist to contact participants. Research team members were in regular contact with the recruiting clinicians and services, including physically attending the service sites on a regular basis, to facilitate and support participant recruitment.An independent scientific committee monitored progress of the project at 14 months, making a recommendation whether to progress to the full RCT, with the final decision made by the Director of the funding body.Ethics approval was obtained from the National Research Ethics Service (NRES) Committee East Midlands - Nottingham 1, UK on 24th September 2014 (REC reference: 14/EM/1084).Descriptive statistics using Stata 13 for variables are presented by treatment arms at baseline and at follow-up with mean (sd) for normally distributed variables, median (range) for skewed variables and frequency (percentage) for categorical variables.Individual qualitative interviews were carried out with 15 staff members from recruiting services , two study non-participants (people who were invited to take part in the RCT but declined), and five participants from the RCT. Interviews were semi-structured using a topic guide and were digitally recorded and transcribed by an experienced qualitative researcher (JR) who helped to recruit participants but was blinded to the allocation and delivery of treatment until all follow-up was complete. All participants gave written consent to the qualitative interviews. Supplementary interviews and feedback were obtained from a service user group of five young people with a history of self-harm who did not take part in the RCT. They did not know the study findings when they were interviewed about the barriers and drivers to taking part in the study (the protocol was presented to them). The qualitative study was designed to understand barriers and drivers to the recruitment and retention of participants to the study. Field notes were also collected by researchers in relation to barriers and drivers to the recruitment and retention of participants, and by the CBT therapist on barriers to the uptake and delivery of the PSCBT interventions.Analysis of the qualitative data (by JR) proceeded in parallel with the interviews and was inductive. Interviews were transcribed verbatim and coding was informed by the accumulating data and continuing thematic analysis , 33. A pFigure Additional file Table There were no adverse incidents in the study but there were unblindings of the research team on safety grounds on three occasions, either at baseline or before the first follow-up assessment (two in the TAU and one in the PSCBT groups): one due to severe self-neglect secondary to severe depression in a participant with no support network; one continuing to exhibit suicidal behaviour with high medical risk; and one admitted to hospital because of escalating self-harm following school exclusion. In each instance, the study team had no ethical alternative but to unblind and signpost to mental health services since the participant had been unable to obtain help from clinical services through their own efforts. For the participant in the PSCBT arm, the unblinding led to withdrawal from the study before the intervention started.The CBT therapist contacted the 10 participants allocated to 10–12 sessions of PSCBT  on 374 occasions  participants had to be withdrawn for safety reasons. Therefore the study was not continued. Three adult participants were recruited in the last month of recruitment through a third sector organisation indicating that recruitment of young people with depression and self-harm, more than 96 h after the last self-harm episode, might be possible in the community. Qualitative interviews  would have offered.In terms of the optimal timing of the clinician approach for participation in the study, there were contrasting views amongst clinicians, study participants and non-participants, and service user group members (see Tables The study age-range (16–30 years) was selected for several reasons. First, up to 60% of self-harm presentations occur in this age range . Second,Previous successful RCTs have recruited by simplifying the recruitment process for front-line self-harm assessment staff by using a Zelen design whereby participants are consented only to one form of treatment and data follow-up  or partiAlternative study designs might have involved clinicians identifying potential participants on the basis of recent self-harm and the research team assessing for depression and its severity at a later stage or possibly embedding a team of full-time researchers (covering 7 days per week) in each self-harm service to enhance recruitment but the latter would be prohibitively expensive. However, the e-DASH study was commissioned to determine the acceptability and feasibility of an RCT of the effectiveness of an intervention that could be delivered in that same format within NHS services. If the intervention had been found to be effective in real-world clinical settings, it could then potentially have been implemented into routine clinical practice i.e. requiring assessing clinicians to distinguish depression severity without the input of a researcher.Further research is now needed on the validity and clinical utility of routine biopsychosocial assessment soon after a self-harm episode or suicide attempt. It is unclear whether psychosocial assessment, admission to hospital or any other intervention reduces repeat self-harm or suicide rates after self-harm . Our datFuture research on PSCBT for people with depression and self-harm should consider offering a choice of face-to-face, mobile phone or internet-delivered treatment at a time when participants feel most ready to engage. Such participants might be recruited in the community through primary care and third sector organisations.In conclusion, recruitment to RCTs of remotely delivered PSCBT for young people with depression and repeat self-harm is not feasible through recent presentation to clinicians in self-harm services. Offering remotely delivered PSCBT did not enhance the uptake of this intervention in participants aged 16–30 years with depression who had recently presented to medical services following self-harm. Such participants may be recruited more readily in the community once the immediate emotional crisis has passed and the participant is less severely depressed.Additional file 1:Study Flowchart (DOCX 57 kb)Additional file 2:Identification of barriers to recruitment and mitigating action (DOCX 17 kb)Additional file 3:Content of one hour pre-therapy session before starting the problem solving cognitive behaviour therapy (DOCX 16 kb)Additional file 4:Content and structure of problem solving cognitive behaviour therapy (DOCX 16 kb)Additional file 5:Efforts made to recruit and retain individuals to the trial by research team (DOCX 18 kb)Additional file 6:Barriers to recruitment among non-participants, from field notes recorded by research team (DOCX 16 kb)Additional file 7:Baseline and outcome scores of participants in e-DASH RCT (DOCX 25 kb)Additional file 8:Attempts to engage participants in the PSCBT intervention (DOCX 18 kb)Additional file 9:Barriers to mobile phone or video internet delivered problem solving therapy (DOCX 17 kb)


Catheter ablation has an important role in the management of patients with ventricular tachycardia (VT) but is limited by modest long-term success rates. Magnetic resonance imaging (MRI) can provide valuable anatomic and functional information as well as potentially improve identification of target sites for ablation. A major limitation of current MRI protocols is the spatial resolution required to identify the areas of tissue responsible for VT but recent developments have led to new strategies which may improve substrate assessment. Potential ways in which detailed information gained from MRI may be utilized during electrophysiology procedures include image integration or performing a procedure under real-time MRI guidance. Image integration allows pre-procedural magnetic resonance (MR) images to be registered with electroanatomical maps to help guide VT ablation and has shown promise in preliminary studies. However, multiple errors can arise during this process due to the registration technique used, changes in ventricular geometry between the time of MRI and the ablation procedure, respiratory and cardiac motion. As isthmus sites may only be a few millimetres wide, reducing these errors may be critical to improve outcomes in VT ablation. Real-time MR-guided intervention has emerged as an alternative solution to address the limitations of pre-acquired imaging to guide ablation. There is now a growing body of literature describing the feasibility, techniques, and potential applications of real-time MR-guided electrophysiology. We review whether real-time MR-guided intervention could be applied in the setting of VT ablation and the potential challenges that need to be overcome. In this context, magnetic resonance imaging (MRI) could play a role in the optimization of VT ablation. Scar and scar borderzone (BZ) are 3D structures—MRI using late gadolinium enhancement (LGE) is the best available technique to define scar in 3D and is a powerful predictor of ventricular arrhythmia risk.The presence of scar detected using LGE-MRI is an independent predictor of sudden cardiac death, recurrent VT, or appropriate ICD discharge in patients with a history of sustained or non-sustained VT.The presence of heterogeneous tissue at the BZ regions between scar and normal myocardium has been more frequently observed in patients with VT compared to patients without VT matched for age, sex, infarct location, and left ventricular ejection fraction.There are subtle aspects of a VT isthmus, however, that can only presently be defined using EAM including entry and exit-sites. The common channel isthmus of VT circuits may also be formed by functional rather than fixed lines of block whilst barriers forming the isthmus may not be clearly visible during sinus rhythm.The transmurality of scar has been co-localized to local electrogram characteristics, however, the relationship remains incompletely understood. A mismatch between infarct surface area measurements on MRI-reconstructed images and EAM using a <1.5 mV bipolar voltage cut-off has been reported in 33% of cases. The areas of mismatch occurred in regions such as the basal left ventricular septum or the posterior wall where achievement of catheter stability and adequate tissue contact may be more challenging during EAM.Critical sites for maintenance of VT have been confined to areas of scar with >75% transmurality and in core–BZ transition sitesEndocardial bipolar voltage mapping with its limited field of view could miss epicardial substrateThe voxel SI of scar on MR images has been used to differentiate between core areas of scar and BZ regions of scar. Using pixel SI thresholds of 60% and 40% of maximum SI to define the distribution of core scar and BZ regions, critical sites for clinical VTs have been identified on MRI when compared with EAM,In vivo MRI invariably suffers from partial volume effects due to insufficient spatial resolution whereby there is a loss of contrast between two adjacent tissue types resulting in both tissue types occupying the same voxel. This may limit the identification of scar BZ areas where the substrate for VT is likely to be located. MRI with high spatial resolution (0.39 mm3) has been used ex vivo in porcine infarct models to minimize partial volume effects and understand the fine 3D architecture of infarcts. The VT re-entry isthmus was characterized by a small volume of normal myocardium bound by scar tissue at the infarct BZ or over the infarct.ex vivo imaging correlated on histology with normal myocardium bordered by collagenous scar .in vivo.Whether MRI can accurately identify the specific regions of tissue that participate in the VT circuit remains an open question. Using the Rhythmia™ high-resolution mapping system in a porcine infarct model the mean length and width of a VT isthmus were reported as 16.4 ± 7.2 mm and 7.4 ± 2.8 mm, respectively.ex vivo MRI as a gold standard, as bipolar spacing increased, the optimal voltage threshold to detect MRI-defined scar also increased, whilst statistically-derived 95% thresholds were not fully sensitive for the detection of non-transmural scar.Whilst some studies have reported a close correlation between areas of MR-derived scar and low bipolar voltage,3) with acceptable scan duration, image quality, and comparable scar characteristics to conventional 3D LGE.Acquisition of high-resolution imaging is required to detect smaller regions of scar and improve assessment of scar geometry in patients undergoing VT ablation.,The development of dark-blood LGE sequences as a technical solution to sub-optimal contrast between scar and blood pool offers promise for improved substrate assessment. Dark-blood LGE sequences have been described that simultaneously reduce normal myocardium and blood pool SI whilst enhancing scar-blood contrast and preserving scar-myocardium contrast.,A major limitation to more widespread use of MRI in patients undergoing VT ablation is the presence of ICDs. Although potential safety concerns have been raised when scanning patients with ICDs including tissue heating adjacent to lead electrodes, induction of arrhythmias, and alterations to device function,Despite the increasing use of MRI-compatible ICDs, not all centres have established scanning protocols in place for patients with ICDs. The in-plane spatial resolution of the wideband LGE techniques reported have also been limited to 1.5 × 1.5 mm with a typical slice thickness of 7–8 mm—this is unlikely to be sufficient for defining the fine myocardial architecture responsible for VT.Table 1) and guide VT ablation . Most of these reports were derived from retrospective analyses on limited series of patients assessing the correlation between MRI-derived scar and EAM.,,,,Using data gained from preprocedural LGE-MRI, a number of studies have attempted to perform periprocedural registration of scar tissue with EAM through image integration (Table 1) whilst some investigators have completed the registration process in real-time, rather than post hoc allowing the electrophysiologist to focus mapping efforts to regions of interest identified through imaging.The registration error reported within these studies have generally been in the range of 3–5 mm .,A potential benefit of real-time MRI guidance over conventional EAM is the ability to visualize soft tissue structures and access detailed information on the chamber of interest and surrounding structures to guide catheters to desired locations within the heart. Both passive tracking  and active tracking  have been used for accurate localization and visualization of catheters during real-time MR-guided interventions  and assess chronic injury. Lardo et al.Magnetic resonance imaging can be used to visualize lesions in real-time, acutely  has emerged as a useful technique in this regard. Protons are surrounded by electrons which act to disturb the local magnetic field during MR scanning.Online monitoring of cardiac temperature during real-time MR-guided ablation appears promising, but there are several challenges to overcome including adequate compensation for artefacts due to respiratory or cardiac motion, assessing accuracy of the technique during irregular heart rhythms and investigating the ability of the technique to predict chronic transmural injury. This tool however, represents an interesting step in exploiting acute physiological changes during ablation using MR to potentially titrate RF energy delivery.Assessment of substrate and delivery of RF energy are only two components of a catheter ablation procedure for VT. Epicardial access or emergency pericardiocentesis may be required during VT ablation—a previous report in a porcine model described the feasibility of real-time MRI-guided subxiphoid pericardial access and pericardiocentesis using passive needle deviceset al.Transcatheter needle chemoablation to target intra-mural substrate has generated interest to improve the efficacy of ablation in selected patient cohorts. In this regard, Rogers The advent of novel emerging technologies such as stereotactic body radiation therapy (SBRT) to deliver ‘radioablation’ and create electrically inert tissue further increases the importance of accurate, non-invasive characterization of substrate. In a recent case series, SBRT was used to deliver catheter-free radioablation to patients with refractory VT with a marked reduction in the burden of VT in all patients.There is currently a lack of commercially available MR-compatible external defibrillator systems. The need to defibrillate urgently during VT ablation and the potential time required to evacuate a patient from a MR scanner bore and perform external defibrillation is a major safety hurdle that needs to be overcome in order to facilitate the uptake of higher-risk MR-guided ablation procedures. In this context, a recent report has described a prototype MR-conditional defibrillation system to successfully defibrillate swine inside and outside a scanner bore.Contemporary electrophysiology procedures in complex arrhythmias are increasingly guided by 3D EAM systems. Current generation MR-compatible catheters cannot achieve the same resolution as multipolar mapping catheters used with high-resolution 3D EAM systems.Radiofrequency-induced tissue heating is an important safety concern particularly when scanning patients with ICDs and it remains unclear what the safety implications may be when performing long procedures under MRI guidance in these patients. In patients with devices that are not MRI-compatible, alternative imaging modalities such as cardiac computed tomography to assess VT substrate  may be more appropriate.Other challenges that need to be addressed include safe anaesthesia and monitoring of patients and ensuring good communication between the electrophysiologist in the MR environment and other healthcare professionals involved in the procedure. Although some of these issues have been navigated in the setting of atrial flutter ablation, performing VT ablation under real-time MR-guidance adds a new dimension of complexity. There is also potentially a steep learning curve for an electrophysiologist in handling and manoeuvring new MR-compatible catheters as well as interpreting MR images for which they may have received little training. Although there is much interest within the electrophysiology community in real-time MR-guided interventions, there are relatively few centres with the resources, expertise and technologies to perform such interventions.Despite the substantial progress that has been made on the use of MRI to guide VT ablation, there is insufficient evidence at present to suggest that the use of imaging can add value to clinical outcomes. Although observational, non-randomized studies suggest that image integration may impact on procedural outcomes, well-designed prospective randomized studies are needed to assess the true impact of image integration as well as evaluate potential mechanisms of any benefit. Further studies evaluating new MRI techniques to distinguish between arrhythmogenic and non-arrhythmogenic scar at high spatial resolution may have downstream effects on improving patient selection for catheter ablation and increased standardization of ablation strategies based on imaging evaluation. Increased standardization in the management of these patients may help reduce workflow discrepancies across centres and potentially impact on the efficacy of ablation.Real-time MRI-guided electrophysiology is a field still in its relative infancy. Further technical development and validation studies are required to improve substrate localization in real-time, corroborate the accuracy of procedural guidance with active tracking and assess the ability of real-time techniques to predict durable ablation lesions. Pre-clinical and clinical studies will be required to standardize workflows for real-time MRI-guided interventions and ultimately compared with conventional VT ablation in order to demonstrate added value.There has been significant progress in the use of MRI to facilitate substrate assessment, integrate data into clinical EAM systems, guide procedures and assess ablation lesions. There is however a lack of prospective randomized evidence to assess if image integration using MR improves the efficacy or efficiency of ablation. There are also a number of technical limitations to using an image integration approach to guide VT ablation. The possibility of real-time MR-guided ablation is intriguing but to date has only been studied in pre-clinical models and patients undergoing atrial flutter ablation. Catheter ablation for VT is likely to reap the greatest benefits from developments in real-time MR-guided electrophysiology but significant challenges need to be addressed prior to clinical studies in patients.This work was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London as well as a Wellcome Trust Health Innovation Challenge Fund grant (HICF-R10-698). Whitaker is a recipient of a Fellowship from the Medical Research Council (MR/N001877/1). The views expressed in this manuscript are those of the authors and not those of the NIHR, MRC, or NHS.Conflict of interest: none declared.


CADENCE-BZ is a multi-centre, parallel-group, double-blind randomized controlled trial designed to examine the clinical efficacy and safety of an accessible food preservative, sodium benzoate, as an add-on treatment for patients with early psychosis. The original study protocol was published in 2017. Here, we describe the updated protocol along with the Statistical Analysis Plan (SAP) for the CADENCE-BZ trial prior to study completion.Two important changes were made to the original protocol: (1) improvements to our statistical analysis plan permitted a reduction in sample size; and (2) a revision in the secondary outcomes with the intent of reducing redundancy and excluding those measures that were not appropriate as outcomes.We provide the updated SAP prior to the completion of the study with the intent of increasing the transparency of the data analyses for CADENCE-BZ. The final participants are currently completing the study and the results will be published in the near future.ACTRN12615000187549). Registered on 26th February 2015.Australian New Zealand Clinical Trials Registry ( CADENCE-BZ is a multi-centre, parallel-group, double-blind randomized controlled trial designed to examine the clinical efficacy and safety of an accessible food preservative, sodium benzoate, as an add-on treatment for patients with early psychosis. The trial was approved by the Metro South Hospital and Health Services Human Research Ethics Committee (HREC reference number HREC/14/QPAH/598). The primary objective was to determine if 12-week treatment with 1000 mg (500 mg twice daily (BD)) of sodium benzoate improves the Positive and Negative Syndrome Scale (PANSS) total score [This paper provides the detailed statistical analysis plan (SAP) and outlines changes to the CADENCE–BZ study protocol. The original detailed protocol has been previously published . CADENCEThe last participant was recruited in August 2018 with the final follow-up visit anticipated to be completed in October 2018. This protocol update and SAP were written to prevent outcome reporting bias , selectiEleven outcomes were listed in the original study protocol. This includes the primary outcome, the PANSS total score, and the secondary outcomes: (1) the Global Assessment of Functioning (GAF), (2) the Clinical Global Impression (CGI), (3) the Hamilton Depression Rating Scale (HDRS), (4) the Assessment of Quality of Life (AQoL), (5) the Opiate Treatment Index (OTI), (6) the Activity and Participation Questionnaire (APQ-6), (7) the International Physical Activity Questionnaire (IPAQ), (8) the Simple Physical Activity Questionnaire (SIMPAQ), (9) the Physical Activity Questionnaire (PAQ), and (10) the Patient Global Impression (PGI-I).The following secondary outcomes will be excluded from the protocol: (i) APQ6, which is a measure of vocational activity and community participation—no studies have demonstrated the APQ6 has sensitivity to change . By contt-test and utilised the conservative assumptions that there are few or no correlations between the baseline and follow-up measures, and that there are perfect correlations between follow-up measures [Our original sample size was based on two-sample measures . Our samp values will be reported. All analysis will be carried out using the SAS software version 9.4. Other software such as R may be used if required.Data analysis and reporting will be done in accordance to the CONSORT guideline . The CONThe analysis will be performed based on intention-to-treat. This will include all randomized participants who complied with the study protocol through the duration of the clinical trial, as well as participants who deviated from the study protocol. We defined treatment compliance as the average number of pills taken per day divided by daily protocol dosage . The analysis will be performed in the per-protocol population by including participants (1) that stayed on the trial for 12 weeks and (2) whose treatment compliance was ≥ 80% (3) with absence of major protocol violation.A recent simulation study has revealed that mixed-effects model repeated measures (MMRM) analysis is robust in maintaining statistical properties of a test when compared to the multiple imputation method in handling missing values , assumin2, t-test) will be computed to compare both treatment groups for each baseline characteristic. These baseline characteristics will be included as a covariate in the multivariable analysis to account for any imbalance that may have occurred by chance between the treatment groups. It is recommended that these variables are adjusted in assessing the primary outcome [Comparisons of participants at baseline will be undertaken for the outcome measures and for the following characteristics: sex, age, living situation, waist circumference, height, blood pressure, and body mass index. Continuous data will be summarized by means and standard deviation. Categorical data will be summarized by number and percentages. Significant test  than those that are more distant in time); and (2) it is appropriate when time periods are evenly spaced. We will also examine the residual to assess model assumptions and goodness-of-fit.The primary outcome measure is the total score of PANSS. Primary outcome will be analysed using MMRM . We willTable The number of treatment-related adverse events (AE) and serious adverse events (SAE) will be reported by their relationship as ‘definitely’, ‘probably’, and ‘possibly’ related to treatment. The number (and percentage) of participants with each AE/SAE will be presented for each treatment arm categorised by (1) preferred term (2), body system, (3) severity. The number (and percentage) of occurrences of each AE/SAE will also be presented for each treatment arm. No formal statistical testing will be undertaken.This update contains the SAP for the CADENCE-BZ trial to avoid the risk of outcome reporting bias and data-driven results. By publishing this where we pre-specify our methods and analyses, it is hoped that the results will be as robust and transparent as possible.


Ensuring competence in communication skills amongst trainees is essential in health professions education. Involving faculty members for the same is a challenge in Obstetrics and Gynecology (OBGYN) due to their clinical commitments. The present study compares scores of OBGYN faculty, non-OBGYN faculty and simulated patients (SPs) on communication skills of postgraduate trainees during formative Objective Structured Clinical Examination (OSCE).This is a psychometric study conducted in Feburary 2017 at the Aga Khan University Medical College (AKU-MC). All thirty-two postgraduate trainees of OBGYN gave consent. Each trainee was assessed by OBGYN faculty, non-OBGYN faculty and SP on communication skills at six stations using nine-point itemized rating-scale during formative OBGYN OSCE. The scores were reviewed using descriptive statistics, reliability was calculated using Cronbach’s alpha and inter-rater reliability was analyzed using Pearson correlation and intra-class correlation coefficient.The score reliability of each of the examiners was >0.7. The mean scores showed that OBGYN faculty were most stringent while SPs were lenient examiners, however, non-OBGYN faculty scored in between. The inter-rater reliability among any two of the OBGYN, non-OBGYN and SP examiner was >0.84 using Pearson correlation and >0.9 using intra-class correlation.The SPs and non-OBGYN clinical faculty can also be used to assess communication and counseling skills on OBGYN OSCEs after required training as examiners. Communication skill is one of the essential competency in health professions.8The training programs on communication skills are scarce, lack of systematic guidance and standardization amid limited clinical opportunities leads to deficient health practices.13Ensuring competence in communication skills amongst trainees through assessments is equally essential in health professions education.A study conducted in Pakistan in 2012 used simulated patient to assess the communication and interpersonal skills of Radiology residents showed correlation between 0.3-0.5 among faculty and SPs.They found that the SP were not fully equipped with regard to training and experience.16The primary objective of this study was to investigate the inter-rater reliability of scores between OBGYN faculty, non-OBGYN faculty and SPs for assessment of communication and counselling skills during OSCE in OBGYN.The secondary objective was to determine the reliability of scores using OBGYN faculty, non-OBGYN faculty and SP as assessors for assessment of communication and counselling skills during OSCE in OBGYN.This is a psychometric study conducted in Feburary 2017 at the Aga Khan University Medical College (AKU-MC). A formative twelve station OSCE examination was organised for the post-graduate trainees in OBGYN. Six of these twelve stations were based on assessment of communication and counseling skills that are included in the present study. These were based on commonly encountered scenarios faced by a physician in OBGYN such as; breaking bad news to a lady whose baby was still birth during cesarean section, revealing a report to the patient with malignancy, taking informed consent before hysterectomy, counselling of patients with gestational diabetes and vaginal birth after cesarean section along with dealing with angry patient whose surgery was delayed due to some other emergency case. Each station was assessed by three examiners: simulated patient, OBGYN faculty and non-OBGYN faculty.Patient-centered observation form (PCOF) was used for scoring having reliability of 0.67. It is user friendly and relevant to our context and community expectations.17Six female SP’s were recruited for the present study with their consent from the SP bank at AKU-MC based on the age, qualifications and years of experience as required. The SPs were trained during a three-hour session on the OSCE scenarios and to use PCOF. To ensure that the SPs understood the use of PCOF for assessment of communication skills, a one-on-one briefing session was held with each SP by the training faculty. Later, each SP demonstrated the scenario with the faculty member in front of the other five SPs. All other SPs were asked to rate the SP faculty interaction using the PCOF form. These ratings were then discussed to ensure standardization of assessment by SPs.Six OBGYN and six non-OBGYN faculty members, who volunteered to take part in this activity were invited as examiners. They were all experienced and actively involved in conducting OSCE examinations as assessors. PCOF was shared via email followed by one-hour training to use the PCOF form for assessment of communication skills.All OBGYN trainees registered for Fellow of College of Physicians and Surgeons Pakistan (FCPS) Part-2 and Member of College of Physicians and Surgeons Pakistan (MCPS) working at AKU-MC and at a secondary hospital campus were invited through email for this formative OSCE. Thirty-two trainees consented to participate in this study. Their age along with years of experience after graduation (MBBS) were noted.Ethical approval was obtained from Ethical Review Committee and OBGYN Department at AKU and The Research and Training Monitoring Cell (RTMC) of the College of Physician and Surgeon, Karachi, Pakistan. (3876-Obs-ERC-15)All data was entered in SPSS 20 for analysis. Descriptive statistics were computed for scores by each assessor, that is, OBGYN faculty, non-OBGYN faculty and SPs. The reliability  of scores by each examiner were analyzed using Cronbach’s alpha. The inter-rater reliability was analyzed through Pearson’s correlation and intra-class correlation coefficient.All 32 trainees appeared in the OSCE. Amongst them, twenty-five were FCPS part-2 trainees while remaining were MCPS trainees. Their mean age was 26 years (SD±2). Their clinical experiences ranged between one to five years.The trainees were assessed by three examiners on each station, that is, OBGYN faculty, non-OBGYN faculty and an SP.The six OBGYN examiners were from the department of Obstetrics and Gynecology at AKU-MC. The non-OBGYN faculty members included three anesthetists, two general surgeons and one medical educationist with a clinical background. All faculty members had an experience of more than five years as OSCE examiners.All SPs had an experience of more than six years of being involved in OSCEs. Four of them had a Bachelors qualification, while the other two had twelve-years of education. The overall reliability of scores on the six communication skills stations for each of the three examiners were >0.7. .The mean and standard deviation of communication skills scores over the six stations for OBGYN faculty, non-OBGYN faculty and SP are also shown in For inter-rater reliability, the Pearson correlation and Intra-class correlation coefficient are shown in Our study compared faculty and simulated patients (SPs) scores on communication skills of postgraduate trainees during formative OSCE. This study showed good reliability of the OSCE scores by all examiners ranging 0.7-0.8 that included simulated patients. The inter-rater reliability of any of the two examiners  was also high (0.8-0.9).The present study showed that if SPs are well trained they can be used as assessors for communication skills. A study conducted on five medical schools in South California showed 94-96% accuracy of recording students’ performance by simulated patients.9The present study showed that SP gave higher scores in comparison to OBGYN and non-OBGYN faculty. Literature shows that SPs give higher ratings when students faced them directly along with facilitated nodding while listening and proper eye contact during the session.21Non-experts are less critical in their marking, if they are not familiar with learning objectives. The students or novice rate themselves as more competent.21This study was limited to one university and the results may not be generalizable. There were all female residents in the present study, and all SPs used were also females. This study can be replicated in other contexts and institutions to see the generalizability of the results.Our study showed an excellent inter-rater reliability among SPs, subject and non-subject expert faculty, therefore both simulated patients and non OBGYN faculty can also be used confidently in formative assessments of communication skills. Non-OBGYN faculty can replace subject experts in high stakes examinations as well after training. On the other hand, the SPs can be engaged effectively and efficiently for teaching and learning of communication skills, as examiners for formative OSCEs along with provision of feedback to trainees. They may also be invited as examiners for summative OSCEs for communication skills with caution as they are lenient on marking with students.


Cyclic deformation at low-stress amplitudes of a rare earth-containing magnesium alloy (Mg–Gd–Y–Zr) was investigated with emphasis on the responsible microstructural relationship between deformation mechanism and fatigue crack initiation. The results show that the microstructural deformation is extremely inhomogeneous at the low-stress amplitudes. Both deformation twinning and non-basal slip are barely observed, and basal slip is the predominant deformation to accommodate micro-plasticity. Fatigue crack initiation occurred at the basal slip bands, causing the morphology of facet on the fracture surface. Therefore, the basal slip is of prime importance in low-stress cyclic deformation and fatigue failure, and fatigue improvement could potentially be obtained through hindering the motion of basal dislocation by microstructural obstacles. Magnesium alloy is an attractive structural material that can be potentially applied in automobile and aerospace industries, due to its low density. However, its strength is relatively low as compared with aluminum alloys. The addition of rare-elements (RE) in Mg alloys could improve the strength remarkably and tailor the deformation mechanisms . The strIt was known that a limited number of independent slip system is available in hexagonal close-packed (hcp) structure at room temperature. The deformation of Mg alloy is generally accompanied by dislocation slip and twinning ,3. As coThis work aims at investigating the cyclic deformation mechanisms at low-stress amplitudes responsible for Mg–RE alloy and unraveling its relation to the fatigue crack initiation mechanisms. The research results of this study may provide a deep understanding of high cycle fatigue failure in rare earth-containing Mg alloys.The material used in this study was an extruded magnesium alloy with a diameter of 10 mm. The chemical composition (wt %) is 10Gd, 3Y, 0.5Zr and Mg in balance. The tensile test  was conducted at room temperature according to the GBT228.1-2010 test standard (Chinese Standard Method). The yield and ultimate strengths of this alloy are 203.8 MPa and 258.1 MPa, respectively. The elongation at the final fracture is 11.5%. In fatigue testing  dimensions of the specimen are presented in It should be noted that the selected zone of EBSD analysis is about 1.0 mm away from the fracture surface, so the obtained results were caused by cyclic deformation instead of crack propagation-induced deformation near the fracture surface.5 cycles). The ratio of the cyclic number (Nc) to total fatigue life (Nf) is inserted within each image. The grain surface became a bit rough almost from the beginning of fatigue test (1.16%), due to the activation of basal slip. Along with the accumulation of micro-plasticity, the grain was filled with slip markings. Finally, a crack initiated from the slip bands as indicated in In order to obtain the crystallographic orientation of the crack initiation site, an area containing secondary cracks on the surface of the specimen at 130 MPa was analyzed by EBSD, as shown in After the crack initiation along slip bands, it would propagate from the surface into the matrix. To gain further understandings of crack behaviors beneath the surface, focus ion beam (FIB) technique was used to section the slip-induced crack. The final fracture surface was observed by SEM to investigate fatigue failure mechanisms. At low-stress amplitudes, the fatigue limit of Mg–Gd–Y alloy is in the range of 100~120 MPa ,7,23, inAt the stress amplitudes below 130 MPa, both twinning and non-basal slip were barely activated. Plastic deformation is mainly accommodated by basal slip. This could be ascribed to increased critical resolved shear stress in polycrystalline Mg alloys;Low-stress deformation in Mg alloy was extremely inhomogeneous, due to its limited slip systems. Slip markings were restricted within isolated grains that have favorable orientation for the basal slip;Fatigue cracks always initiated along surface slip bands, and then propagated into the matrix straightly along basal plane, resulting in facet morphologies at fracture surface;Since basal slip was responsible for predominant deformation and fatigue crack initiation, introducing of specific microstructure or interfaces that are capable of hindering <a> dislocation may significantly improve high cycle fatigue strength.Cyclic deformation mechanism of a rare earth-containing Mg alloy at low-stress amplitudes was investigated for further understanding of high cycle fatigue crack initiation. The following main conclusions can be drawn: