Agenesis of the corpus callosum is a rare congenital defect that has been linked to psychiatric disorders, cognitive deficits, learning disabilities, and developmental delays. We present the case of a patient with partial agenesis of the corpus callosum who exhibits depressed mood, transient loss of memory, and history of cognitive, social, and behavioral disturbances that developed during his childhood. Recent and pertinent literature was reviewed and the agenesis of the corpus callosum and its associated neuropsychiatric manifestations are discussed. The implication of the partial agenesis of the corpus callosum in the development and manifestations of a psychiatric disorder is not fully understood. The corpus callosum is the most massive white matter structure in the brain that is involved in the exchange of information between the cerebral hemispheres. The corpus callosum develops between the eighth and 20th week of pregnancy, and its development can be halted during this period . CompletThese neuropsychiatric disturbances notably observed in patients with corpus callosum anomalies have raised questions regarding the effect of corpus callosum atrophy and agenesis. The current literature demonstrates potential associations between features of psychosis and corpus callosum degeneration or agenesis –6. PreviWe describe the case of a 45-year-old Hispanic man who presented to the psychiatric emergency room on account of depressed mood and forgetfulness. He was found by his niece sitting in the bathroom batting away imaginary flies and crying, stating that he could not remember anything which prompted his niece to call emergency medical services (EMS).The patient was emotionally labile and could not remember his name or address at the time of presentation. He was hyperverbal and difficult to interrupt, and his speech was disorganized. The patient stated that prior to admission, he left his home and suddenly could not remember how he got to the location he had traveled to. He then returned home and entered the bathroom to look for a belt to hang himself with, because he could not remember any of the evening's events. He stated that he felt lonely and helpless and that he had suicidal thoughts. The patient stated that his sleep had been poor. He endorsed a perceptual disturbance of seeing fleas that were trying to infest his body. He also endorsed an auditory hallucination of a male voice calling his name. Collateral information from his niece, who called the EMS, revealed that the patient had been acting bizarre with two previous episodes of new-onset wandering behavior in the past six months, both associated with heavy alcohol use. She also reported that the patient had a 15-year history of schizophrenia and that he had had similar episodes in the past, which were usually brief and resolved without the need for hospitalization. During a similar episode three years ago, the patient began attacking his family members and was hospitalized after the police were called. The patient also received a diagnosis of major depressive disorder five years ago. The patient was admitted to the inpatient psychiatry unit with a diagnosis of major depressive disorder. Urine toxicology at the time of admission was negative for controlled substances, illicit drugs, and alcohol. The patient's admission Complete Blood Count (CBC) and kidney liver function tests were within normal limits. Rapid regain test was negative. Serum sodium and potassium were 138mmol/L (136–144.0mmol/L) and 4.4mmol/L (3.6–5.1), respectively. Other routine urine analyses and coagulation profiles were also within normal limits as were routine chest radiograph and ECG. Serum thyroid stimulating hormone was below the lower limit of normal 0.409 uIU/ml  and free T4 was 1.09 ng/ml (0.82–1.77 ng/dL). The patient had no symptoms of hyperthyroidism.Other chemical laboratory investigations were within normal limits except for dyslipidemia. Computerized tomography (CT) and magnetic resonance imaging (MRI) performed during admission revealed partial agenesis of the corpus callosum with the absence of the posterior body and the splenium as shown in On day 1 of hospitalization, the patient was hyperactive and restless on the unit. He was treated with escitalopram 10 mg PO daily and risperidone 2 mg PO BID. By day 2 of hospitalization, the patient was able to recall his name and his perceptual disturbances resolved, but he was still hyperverbal, with increased activity. By day 9 of hospitalization, the patient's condition had stabilized, and he was discharged.According to the patient's mother, the pregnancy was reported to be complicated at five months, and the patient was born at seven months. He had normal gross motor development, but language was delayed until the age of 7 years. The mother reported a history of cognitive developmental delay and intermittent behavioral disturbances that led to his dropping out of school in fifth grade.We conducted a literature review to explore various neuropsychiatric manifestations of agenesis of the corpus callosum presented in this case report. This was focused on identifying peer-reviewed articles related to partial agenesis of the corpus callosum and pathology. We searched PubMed, EBSCO, and Web of Science for articles on the function of the corpus callosum and presentation when absent or when there is a lesion without language restriction or restriction to time-period. The search was conducted using the keywords and MeSH terms: “function” “agenesis” “corpus callosum”, “schizophrenia”, and “psychosis.” Screening for eligible articles was conducted independently by six authors. Eligible studies were those that focused on the symptomatology of agenesis of the corpus callosum or defect in the corpus callosum and the respective psychiatric manifestations in human subjects. The citation manager used was Endnote in order to prevent duplication of references.Because of the rarity of agenesis of the corpus callosum, all types of studies were considered for analysis including experimental, meta-analysis, cohort, case-control, case series, and case reports. The pertinent information from the included articles was abstracted and entered into a data abstraction form using Microsoft Excel constructed by the group. The information extracted from eligible articles includes the title of the article, gender and age of the patient, signs, symptoms elicited, and lab findings/imaging recorded.A summary of the cases from the review of literature is shown in Reported symptoms ranged from changes to behavior and personality, including paranoia, hallucinations, and delusions, to cognitive impairment. Radiological findings of the patients varied; however it mainly included agenesis or atrophy of the corpus callosum, followed by lipoma of the corpus callosum.The case presented is a patient with partial agenesis of corpus callosum with a previous diagnosis of schizophrenia and recurrent transient loss of memory, who presented with mood disorder which resolved within two days during treatment with a combination of antidepressants and antipsychotics. Other probable nonpsychiatric contributors to this presentation were ruled out in the context of normal laboratory findings and the findings from neurologic examination.Lesions in the corpus callosum have been implied in the etiology of psychiatric disorders; however, the pathophysiologic mechanism is not understood. Studies have shown that the size or thickness of the corpus callosum area is smaller in individuals with schizophrenia when compared to those without schizophrenia –22. FurtResearch has suggested that ‘‘asymptomatic” individuals with agenesis of corpus callosum (ACC) nevertheless have areas of specific cognitive deficit or learning disability . As of yAgenesis of the corpus callosum is a rare condition that is commonly known to be associated with seizures, developmental delays in motor and language skills, and sensory impairment. In addition to these symptoms, there have been multiple findings supporting the association between ACC and neuropsychiatric manifestations such as depression, schizophrenia, bipolar disorder, learning deficits, epilepsy, and conversion symptoms. The findings from our case presentation further support that there is a connection between ACC and the onset of mood and psychotic symptoms. Corpus callosum anomalies interfere with the communication and regulation of activity between the two hemispheres and manifest with these abnormal symptoms. Further studies of mental disorders in patients with ACC are necessary to increase our understanding and awareness of the cerebral basis of many mental health conditions.


The present document describes the SIUMB  guidelines for the use of ultrasound in the management of focal liver disease. The aim of the paper is to provide a clinical practice guideline for Italian physicians who are approaching the ultrasound study of a focal liver lesion. In particular, these guidelines provide simple indications, recommendations and general practice advices for the correct use of contrast-enhanced ultrasound (CEUS) in this scenario. They represent the SIUMB position of the ultrasound role in the diagnostic flow charts of the principal focal liver lesions, and are in agreement with other, previously published national and international guidelines. This document represents the results of the Italian Society of Ultrasound in Medicine and Biology (SIUMB) guideline committee’s research concerning the use of conventional and contrast enhancement ultrasound in focal liver disease. In 2016, we started collecting data from literature  published over the past 10 years about the role of contrast-enhanced ultrasound (CEUS) in focal liver disease. Recommendations were formulated on the basis of the data analyzed. They were then evaluated by a panel of Italian physicians, experts in the use of ultrasound in focal liver disease. This “Consensus” was held in Rome, on 20 November 2017, during the last national conference. The results of the expert committee’s work were presented to SIUMB members on 21 November 2017, and the text, including recommendations, was then approved by the SIUMB executive bureau on 20 January 2018. This document is the summary of the SIUMB’s position regarding the use of contrast-enhanced ultrasound in focal liver disease. It aims to be a guideline to define the situations which are appropriate to propose a more sophisticated ultrasound imaging technique, such as contrast-enhanced ultrasound (CEUS), and when other imaging techniques need to be used.The importance of ultrasound, and in particular the use of ultrasound contrast agents (UCAs), is well recognized in Italy, but we missed a guideline document developed by SIUMB. In the light of this lack, and on the strength of two decades’ experience using contrast-enhanced ultrasound, SIUMB set up a guidelines committee.Ultrasound in Medicine and Biology and in Ultraschall in der Medizin/European Journal of Ultrasound) [In the first meeting, held in Rome in September 2016, the authors carried out an analysis and selection of the already-published guidelines concerning the contributions of unenhanced and enhanced ultrasound to the diagnosis of focal liver lesions. The European Federation of Societies for Ultrasound in Medicine and Biology ( EFSUMB) guidelines, published for the first time in 2004, and updated in 2008, and the World Federation For Ultrasound in Medicine and Biology (WFUMB)–EFSUMB guidelines, in particular, were evaluated. The latter, published in 2013, represent the worldwide guidelines  decision not to consider the use of CEUS in the diagnostic flow chart of a new nodule developed in patients with chronic hepatitis or cirrhosis, after its role had already been recognized in previous guidelines published by the same society in 2005 , 5. The The American College of Gastroenterology (ACG) clinical guideline concerning the diagnosis and management of focal liver lesions, published in 2014, presented CEUS as an emerging modality that had some utility, especially in the diagnosis of benign lesions like hemangioma and focal nodular hyperplasia (FNH), but was not widely available in the United States. For this reason, the authors preferred to focus their attention on contrast-enhanced computed tomography (CECT) and contrast-enhanced magnetic resonance imaging (CEMRI) .Finally, we evaluated two additional guideline documents. The first, published by the European Association For the Study of the Liver–European Organization for Research and Treatment of Cancer (EASL–EORTC) in 2012, which concerned the management of hepatocellular carcinoma, did not include any indications for the use of CEUS. The second, the European Association for the Study of the Liver (EASL) clinical practice guidelines on the management of benign liver tumors, published in 2016, acknowledged CEUS a diagnostic role in all benign lesions except for adenoma , 11.To be complete and comprehensive, we evaluated two other documents after analyzing the international guidelines. These two documents were written in Italian. The first was published by the Ministry of Health in September 2008, as part of our national system of guidelines (SNLG). It was the first Italian document concerning the use of imaging in the diagnosis of focal liver disease . The latAfter the analysis of international and national guidelines, the second step was to evaluate the most important papers on the role of conventional and contrast-enhanced ultrasound in the management of patients with focal liver lesions. To do that, we carried out a bibliographic search by entering the following terms in PubMed: “liver cancers and ultrasound and contrast enhanced ultrasound.” The research was limited to the period between 2006 and 2016, and led to the identification of 899 articles. By activating filters for clinical trials, review and meta-analyses, we reduced these to 77 clinical trials, 132 reviews, 11 systematic reviews, and 4 meta-analyses –17. We pIn drafting the final document, we decided to report the conclusions of the existing literature as recommendations, and to include the experts’ opinions on all the focal liver lesions presented.The evidence for and strength of the recommendations were assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system . The strThe SIUMB’s experts committee voted on each of the statements. Each member of the committee had the ability to approve, disapprove or abstain from voting on a particular statement. A strong consensus was reached when there was agreement in > 95%, while broad consensus was achieved when > 80% of the experts agreed.Ultrasonography is usually the first imaging technique adopted by clinicians to study the liver. Its widespread use brought great advances in clinical hepatology. Before the advent of ultrasound and other imaging modalities like CT or MRI, it was almost impossible to discover focal liver lesions in asymptomatic patients, and the natural history of liver tumors was almost unknown to clinicians. Real-time ultrasonography is the most frequently used imaging procedure for primary diagnosis of focal liver lesions and in the survey of patients affected by chronic liver diseases and tumors of the gastrointestinal tract . The evaGenerally, detection is made via B-mode ultrasound. In most cases, it is not possible to characterize and differentiate benign from malignant lesions using this mode, since it lacks specificity in characterizing focal liver lesions . The chaThe unique ultrasound contrast agent licensed in Italy and in Europe is Sonovue . It consists of bubbles that have a flexible shell, allowing them to oscillate when insonated at a low mechanical index (MI). MI is a parameter that measures the acoustic power of the ultrasound beam and determines the harmonic echo frequencies, coming from the resonating bubbles, which can be constantly imaged in real time. The low mechanical index imaging technique has become the method of choice adopted by all the companies which produced ultrasound scanners. This method avoids the destruction of the bubbles and provides continuous dynamic imaging, which allows for the assessment of the arterial inflow, capillary distribution and venous outflow within a parenchymal organ. In turn, this enables the study of both macro- and microcirculation. Indeed, the size of the microbubbles allows free passage through the capillaries. Sonovue is distributed within the whole blood volume, but does not diffuse into the extracellular fluid space. A low mechanical index imaging technique using a second-generation ultrasound contrast agent has become the method of choice for the detection and characterization of focal liver lesions. The signal coming from the bubbles is detected by contrast-specific US modes, which work by erasing the linear ultrasound signal coming from the tissue and using the nonlinear responses from microbubbles to form images . Each maSonovue is administered by an intravenous bolus injection , followed by a flush saline solution to push the agent into the central venous stream. The recommended dose for a single injection is half a vial, which amounts to 2.0–2.5 ml. However, the optimal dose for a particular clinical situation depends on the scanner technology used, and should be adjusted accordingly. The intravenous cannula should be at least 20 G in caliber, and the syringe should be connected directly or via the straight line of a T-connector. In this way, it is possible to avoid excessive mechanical stress during injection and prevent the destruction of the stable microbubbles .UCAs are safe, with very rare side effects and an excellent tolerance in clinical practice. The incidence of severe hypersensitivity event is lower than that for CT contrast agents, and is comparable to that of MRIs. In abdominal applications, the incidence of life-threatening anaphylactoid reactions is 0.0001%, with no deaths in a series of > 23,000 patients . Ultrasoto ensure every patient provides informed, written consent before an examination is done;to work in a laboratory in which there are resuscitation facilities;to be careful with patients with a history of severe coronary disease; andto avoid using ultrasound contrast agents for 24 h before extracorporeal shockwave therapy.Although there is a theoretical possibility that the interaction of diagnostic ultrasound and UCA could produce bioeffects, there is no clinical evidence for adverse effects on human liver. For safety reasons, and to align with other guidelines, the SIUMB’s recommendations are:Generally, contrast-enhanced ultrasound (CEUS) is performed after a gray-scale B-mode ultrasound, which represents the first step of the examination. It should be kept in mind that if the baseline ultrasound is suboptimal, CEUS may be unsatisfactory . For besThe liver has a double blood supply, which consists of an arterial and a portal flow. 70% of the blood support arrives through the portal vein, while the remainder arrives via the hepatic artery. Considering that microbubbles trespass the capillary bed, we have to follow the dynamic change of the enhancement during the arterial, portal and parenchymal, or late, phase Table . The artThe appearance of a lesion during the contrast mode should be described in terms of degree of the enhancement in all the phases. The term “enhancement” corresponds to the grade of perfusion with respect to the rest of the liver parenchyma. In this way, we can distinguish four perfusion patterns, which are, respectively, called hyperenhancement if there is hyperperfusion, hypoenhancement if the lesion is hypoperfused, and isoenhancement if it shows the same perfusion of the rest of the liver. Finally there are also not perfused lesions, in which there is no enhancement because there are no vessels inside.The arterial phase is useful in the evaluation of the behaviors of the vascular arterial supply. In particular, it allows to focus on the type and timing of the filling . Portal and late phases are more important, because in these phases, we can determine if the lesion is benign or malignant. A lesion that shows a decrease in the enhancement with a hypovascular aspect is typically malignant; while, if the lesions are iso- or hyperenhancing in the portal or late phases, they are typically benign. According to the literature, the smallest lesions that are detectable with CEUS range between 3 and 5 mm in diameter .healthy patients with no history of cancer;patients with a history of cancer; andpatients with a history of chronic hepatitis or cirrhosis.Before performing an ultrasound examination (B-mode and/or CEUS), it is also important to take the time to collect information concerning the clinical aspects of the patient’s life. This can help to produce a better diagnostic outcome. First of all, it is important to consider the age and the sex of the patient. In fact, the probability of finding a malignant lesion in a young person is lower than in an older patient. At the same time, the probability that particular kinds of focal liver lesions, like FNH or HCA, will be detected is higher in female patients. Another important issue is to know the clinical history of the patient. We can distinguish between three general scenarios:Being aware of the clinical background can help us to better understand and forecast the type of lesion we are studying. For instance, oral contraceptive use in the absence of underlying liver disease could be suggestive of hepatocellular adenoma, while a new lesion identified in a patient with chronic hepatitis could be highly suggestive of HCC. The detection of a new lesion in a patient with a previous history of tumors could be suggestive of a secondary liver lesion.The following paragraphs describes the ultrasound aspects of focal liver lesions, putting in evidence unenhanced and enhanced ultrasound behaviors. Rare tumors are not discussed in this document, because at the moment there is not enough evidence for their detection with CEUS. There also indications and recommendations about following diagnostic flow charts in those cases in which ultrasound is not able to characterize a focal liver lesion. All the statements that follow represent a summary of the discussion which occurred during the SIUMB’s experts’ committee meeting, and constitute the Italian guidelines for approaching the study of a focal liver lesion.The benign focal liver lesions discussed in the following paragraphs are hepatic cyst, hydatid cyst, hemangioma, focal nodular hyperplasia, and adenoma. Focal fatty change was not considered properly a lesion, even though it can look like a mass, especially when hypoechoic and located in unusual sites. As an area of focal fatty infiltration or fatty sparing, it does not differ in vasculature from the surrounding liver tissue. In a contrast-enhanced ultrasound, it shows the same enhancement pattern as adjacent liver parenchyma in all the phases. Regenerative nodules are benign lesions developed in patients with cirrhosis, which generally show the same enhancement of the surrounding liver tissue, even though during the arterial phase, it could be possible to find a hypoenhanced aspect. The most important behavior of all the benign lesions in CEUS is that all of them show sustained enhancement in the portal and late phases. Their characterization depends on the type of enhancement during the arterial phase.Ultrasonography is highly accurate in the characterization of simple hepatic cysts, especially when typical features are present . Its sensitivity and specificity rates are higher than 90% . A simplThe sensitivity of ultrasound for evaluation of Echinococcus is 90–95% . The ultHepatic abscesses can appear in ultrasound as hypoechoic or hyperchoic lesions, depending on their size and the evolutionary status. Generally, however, they occur as hypoechoic lesions, with irregular walls and variable content  . Their cThe typical ultrasound appearance of hepatic hemangioma is as a hyperechoic lesion with well-defined margins, but sometimes its aspect can be hypoechoic or inhomogeneous creating diagnostic doubts, especially in patients with oncological history or affected by chronic liver disease. The advent of contrast-enhanced ultrasound (CEUS) has improved both the sensitivity and specificity of US, reaching a high level of accuracy in the non-invasive diagnosis of the condition , 30–32. The B-mode ultrasound behaviors of FNH are variable, but it is usually slightly hypoechoic or isoechoic, and very rarely hyperchoic. The central scar is visible on ultrasound in 20–30% of cases. After color Doppler evaluation, the lesion is hypervascularized, with hypertrophic vascular arteries that have the appearance of a spoked wheel. The lesion is characterized by vessels that rise from the center to the periphery of the nodule. Spectral Doppler analysis shows an arterial flow with a low resistive index.When there are typical vascular characteristics, CEUS, CECT and CEMRI are able to reach a specificity level very close to 100%. In contrast-enhanced ultrasound, this lesion shows a rapid filling, starting from the center and moving out to the borders, with a centrifugal progression. In the arterial phase, it can take on a hypervascular aspect that can be maintained in all the phases, or it can show an isovascular appearance in the portal or late phase, comparable to that of hepatic parenchyma –36. In tThe ultrasound aspect of the adenoma is variable and is conditioned by size, necrotic hemorrhagic evolution, and adipose content. Although study with color Doppler can document vascular signals, both arterial (with a reduced resistive index) and venous (both on the periphery and in the center), these aspects are not pathognomonic. CEUS is indicated for the differential diagnosis compared to the other focal liver lesions, but it is not accurate in confirming the diagnosis of adenoma or classifying the subtype , 38, 39.The available data on rare focal liver lesions do not allow for the formulation of diagnostic recommendations.Strong consensus (35 approved/0 disapproved/0 abstained. 100%).The malignant focal liver lesions discussed in the following subchapters are hepatocellular carcinoma, cholangiocellular carcinoma and metastasis, which represent the most common malignant masses. This document does not address other malignant lesions like lymphoma, epithelioid hemangioendothelioma or cystoadenocarcinoma, which are rare, and will be discussed elsewhere. Generally, all the malignant lesions show a hypoenhanced aspect in contrast-enhanced ultrasound during the portal or late phase, and the diagnostic accuracy of the method is very high –17.Ultrasonography is the imaging test universally proposed for the early detection of HCC in surveillance programs for cirrhotic patients. All patients with cirrhosis in Child–Pugh Turcotte (CPT) A or B, and those on the waiting list for liver transplantation, must be evaluated with periodic ultrasound . The ultIf imaging patterns are inconclusive after CEUS and CECT or CEMRI, biopsy should be performed. When portal vein thrombosis is present, CEUS allows the clinician to characterize the nature of thrombosis (neoplastic vs not neoplastic). In the case of neoplastic thrombosis, the thrombus appears “hypervascular” in the arterial phase, with washout in the portal and late phases.  Strong consensus (35 approved/0 disapproved/0 abstained. 100%).Intrahepatic cholangiocarcinoma (i-CCA) appears in conventional ultrasound as a nodular lesion that if < 3 cm, is most often hypoechoic, but the ultrasound aspect is completely indistinguishable from other liver lesions. The presence of segmental ectasia in the upstream biliary branches of the lesion can be suggestive, but is not specific to the diagnosis. Color Doppler has no role in the diagnosis of i-CCA.In CEUS, the i-CCA behaves like a malignant lesion, characterized by a washout in the portal and late phases. Generally, the duration of the washout is shorter than that of HCC, and starts in the portal phase , 44. TheThe ultrasound aspect of metastatic lesions of the liver is variable, and can include any ultrasound appearance. Although ultrasound examination is frequently requested at the first diagnosis and during follow-up in patients with oncological disease, the sensitivity of conventional ultrasound in the detection of liver metastases is lower than that of second-level imaging techniques . This is particularly true when lesions are < 1 cm. Color Doppler US is not indicated for the study of hepatic metastases. In CEUS, hepatic metastases are characterized by washout in the early portal phase . The acc


N = 345 interviews) in one of the most fire-prone areas in Europe (NW Spain) in order to assess citizens’ awareness about wildfire causes and risks, their perception of the value of the vegetation and of administrative measures to fight against fires. Perceptions of respondents about fire causes were in general realistic although fires caused by pyromaniacs and for profit were overestimated, while vegetation management was comparatively underestimated. Citizens were broadly aware of the fire risk associated with different vegetation types, rightly considering native oak forests and agricultural fields as less risky than shrublands and pine and eucalypt plantations. Tree-dominated vegetation was more valued than treeless formations, and native forests more than tree plantations, which seems related to a preference for ecological value over utilitarian considerations. In addition, the value of eucalypt plantations was clearly affected by the education level of respondents, being less valued as the education level increased. Most citizens considered that the administration was not doing enough to fight against fires. The law that compels landowners to reduce fuels in wildland-urban interfaces was considered effective by most respondents (72%), but 50% considered it difficult to implement by landowners. This may explain the poor degree of compliance of this law.Exploring the human dimensions of forest fires is a crucial, although often overlooked, aspect of wildfire research, since wildfires often have important socio-economic impacts and humans are nowadays the main cause of wildfires in many areas of the world. We carried out a telephone survey ( Fire is a natural agent that has shaped natural landscapes and species adaptations over millions of years and has a significant role in the Earth system . HoweverAssessing public opinions and attitudes has become an important tool to support management decisions that are acceptable to the public, and to develop communication and environmental education strategies . It is aPeople’s views regarding the environment depend partly on characteristics of the individual and its context. Characteristics such as age, gender, education, and place of living constitute well-studied social bases of environmental concern and environmental risk perceptions . When diIn the study area (NW of Spain), as well as in other areas of the world , some ofOne of the most common approaches to manage fire risks focuses on fuel reduction activities, especially in wildland–urban interfaces, where the risk of fire is higher . When thOur goal in this study is to assess public awareness and attitudes regarding wildfires. We focused on wildfire causes, the risk associated with the type of vegetation, the value of this vegetation and the management measures implemented by the administrative authorities. More specifically, we analyse public views in relation to the relative importance of wildfire causes, including general causes, classified as deliberate, negligent, accidental or natural, as well as to more specific causes related to human behaviours and activities. Since the type of vegetation is one of the main factors determining fire proneness in a given area and, in contrast to other important factors such as topography or weather, it is subject to active management, we analyse in this study people’s views on the relative wildfire risk associated to the most common vegetation types in the region, as well as the perceived value of these vegetation types for the people. Since the administration has a prevalent role on fire management, we were also interested in determining public views about the role of the administration. Specifically, we analysed whether people considered that the administration was doing enough in the fight against fire, people’s view about the importance of implementing different possible improvements of fire fighting measures, and their views on a management measure designed to mitigate fire risk in the wildland-urban interface, since public views can determine the success or failure of administrative measures. We analyse general trends as well as differences across subgroups of the population, according to age, gender, educational level, residence in rural or urban areas and engagement in activities in the wild. We determine the degree of realism of public views by comparing respondents’ perceptions with real data from official reports, when available (for fire causes and the fire risk associated with different types of vegetation). As far as we know, this is the first study analysing the realism of public views in this regard.The study was conducted in NW Spain, which has one of the highest incidence of wildfires in Europe . This exThe study was carried out in Galicia (NW of Spain) which, similar to other regions of Southern Europe, has a very high incidence of wildfires. In the last decade (period 2005–2014), Spain had ca. 22% of all wildfires recorded in Europe and 30% of the burned area, and the NW is the region of Spain with the highest fire incidence . In fact2 in 2016, with 2,718,525 inhabitants in an area of 29,575 km2; INE–National Institute of Statistics) which increases the contact between the people and the wildland in the so called wildland-urban interfaces, which represent 8% of the total area  using randomly selected phone numbers from the White Pages directory, selecting respondents older than 18 yrs old . We made a total of 1,449 phone calls and the response rate was 24%. The survey was carried out in February-May 2016 and consisted of eight questions organized in three thematic parts (see Ulex spp. and Cytisus spp.) and Ericacea   and activity . Respondents were classified according to age in three groups: young adults (between 18 and 40 yrs old), middle-aged adults (41–65 yrs old) and senior adults (over 65 yrs old). The educational level was classified in three groups, lower educational level , middle educational level , and higher educational level .The questionnaire was carried out anonymously. No personal information of the respondents was recorded. The study was approved by the University of Vigo’s Research Ethics Committee (201800004201). Before starting the questionnaire, participants were informed that this was a study of the University of Vigo about wildfires in Galicia, that their participation was voluntary and anonymous, and that they could terminate the interview at any time. The interviews started once participants provided their verbal consent. The whole interview, including an introduction and the questionnaire took about 15 min on average.We used ordinal logistic regression to analyse the answers to most questions (except for questions 5 and 7). We analysed whether there were differences between answer options , and the effects of the interactions between the answers and demographic groups, in order to analyse whether there were differences between groups in their answers to our questions. Questions 5 and 7 were analysed with Pearson’s chi-squared tests, using contingency tables to test the independence between two categorical variables in order to analyse whether there were significant differences between demographic groups in the frequency in which they selected the different options given in the question. We used IBM SPSS Statistics for Windows to perform these analyses.P = 0.084). Respondents were between 18 and 92 yrs old, and there were significant differences between the proportion of age groups in our sample compared to the population (P < 0.001), with a lower percentage of young adults , and a higher percentage of both middle-aged  and senior adults . Regarding educational level, 27% of respondents had lower educational level, 49% had a medium level and 24% had higher educational levels, percentages that did not differ significantly from those in the population (P < 0.389). Respondents living in urban areas reached 71% and 29% resided in rural areas, while the percentage of respondents doing some activities in nature was 48% vs. 52% of respondents doing no activities in nature.The percentage of women and men in the sample (57% of women and 43% of men) did not differ significantly from that in the population  as being different in terms of frequency of fires caused by them. There were some differences  between male and female participants and educational levels in the relative frequency they assign to different causes, as revealed by the significant interactions with these factors , althougWhen looking at the more specific fire causes  among people with higher educational levels, in contrast with respondents with lower educational levels, which gave more importance than the more educated to natural causes and anthropogenic but involuntary causes . This might be related to a more questioning attitude of the more educated people regarding human responsibility for environmental problems .In regard to more specific causes, the role of pyromaniacs  was clearly overestimated, as was that of deliberate fires caused for profit. The incidence of fires caused by pyromaniacs is often overestimated, not just by the general population but even by fire reporters and officials, due to the poor understanding of this mental disorder, so that the term pyromaniac is often wrongly applied to people that set fires deliberately (arsonists in the strict sense), even when no mental illness has been diagnosed . A good The consideration of vegetation management as less important than pyromania and profit-driven fires was unrealistic, since it is, in fact, the most important specific cause in the study area . This was due to an overestimation of pyromania and of fires caused for profit rather than to an underestimation of the frequency of fires related to vegetation management. These fires correspond mostly to agricultural burnings for waste disposal. Their high frequency has led authorities to develop strict regulations in this regard, banning all agricultural burnings in summer and making it compulsory to ask for specific permits the rest of the year, so that rangers are aware and can supervise the burning. There is a lack of awareness in the population about vegetation management being a major cause of wildfires, which highlights the importance of information campaigns, since the effectiveness of preventive measures depends on the wise behaviour of thousands of landowners that dispose of their vegetal waste every year. The strategy followed by the administration to reduce the high incidence of vegetation management as a cause of wildfires has been based on imposing strict regulations. However, farmers still use fire as a management tool, and this causes a great number of fires every year. Reducing the risk of this routine practice is needed. To this end, education and training campaigns especially focused on this particular cause of wildfires should be promoted, in order to raise awareness of the danger involved as well as to show how to improve safety when using fire.Ranching was rightly considered as relatively infrequent but somewhat underestimated in comparison with other causes such as natural causes, hunting or conflicts. Fires related to ranching occur mainly in shrublands , where fThe realism of public perceptions about the fire risk associated with different vegetation types, considering agricultural fields and oak forests as the less fire prone, is in accordance with real data , which iP. radiata are non-native in this region) while eucalypts are recognized as alien species  and the importance of fires motivated by profit gaining. Our results highlight the importance of the educational level in affecting citizens’ views; more educated people was more critical with the role of the administration and attributed less value to eucalypt plantations, an economically important but controversial land use due to its non-native status in the area. In line with citizens’ preferences, a more proactive approach in the fight against fire is recommended, focusing more on prevention than in suppression. Among preventive measures, those focusing on changing behaviours of individuals are especially recommended, since most fires are caused by humans in this region. Information and training campaigns, which have been especially favoured by people with higher educational level, can be especially useful in this regard. More constructive and focused campaigns targeted at specific segments of the population are recommended, in particular to improve awareness of the risk and increase the safety of some particularly hazardous activities. Among them, the use of fire for vegetation management in agriculture requires the most attention, since it is a major cause of wildfires every year. There is an urgent need for people using fire in this activity to understand the danger involved and to improve their knowledge and skills in order to make a safer use of fire. The low value attributed by citizens to shrublands is also of concern. More appreciation for this type of vegetation should be promoted, as reduced appreciation may result in lower attention from the population to prevent and suppress wildfires. Our study also reveals a very interesting result in regard to citizens’ views about to the law that compel landowners to reduce fuels in the wildland-urban interface. Although it is viewed by most as an effective measure, it was considered difficult to implement, which likely explains the low degree of compliance of this law. For a more realistic and economically sustainable alternative, we recommend promoting native oak forests, making use of their high fire resistance and resilience, their minimal management requirements and high ecological value, in addition to being highly appreciated by citizens, as our study have shown. Considering the huge cost of fire fighting in this region, taking advantage of the adaptations of the native vegetation to reduce fire risks is recommended as an alternative aimed at maximizing the ecological benefits while minimizing socio-economic impacts.10.7717/peerj.5657/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.5657/supp-2Supplemental Information 2Data corresponding to the answers of the respondents to the questionnaire.Click here for additional data file.


Ecosystem services (ES), as an interconnection of the landscape mosaic pieces, along with temporal rivers (IRES) are an object of research for environmental planners and ecological economists, among other specialists. This study presents (i) a review on the importance of IRES and the services they can provide to agricultural landscapes; (ii) a classification tool to assess the impact of IRES to provide ES by agricultural landscapes; (iii) the application of the proposed classification to the Caia River in order to identify the importance of this intermittent river for its surrounding agricultural landscape. The classification of the ES follows the Common International Classification of Ecosystem (CICES) classification that was adapted for the purposes of this study. Firstly, the list of ES provided by agricultural landscape was elaborated. In the next step, we assessed the potential of IRES to provide ES. Next, IRES impacts to ES within the agricultural landscape were evaluated according to observations from the conducted field monitoring in the study area. This study focuses on the relevance of the intermittent Caia River—a transboundary river in Spain and Portugal—and its ephemeral tributaries in the agricultural landscape. Our study estimates that each hydrological phase of IRES increases the ES provided by the agricultural landscape. However, the dry phase can potentially have negative impacts on several services. The intensification of the agricultural sector is the main provision of the water resource within the Caia River basin, but we were able to identify several other ES that were positively impacted. The present study is in line with the conclusions of other authors who state that IRES constitute a valuable resource which should not be underestimated by society. Landscapes are mosaics formed by different land use elements interacting among each other. Each element of the mosaic provides several benefits and stressors, services and disservices to the whole ecosystem ,2,3. MosThe general definition of Ecosystem Services (ES), provided by the Millennium Ecosystem Assessment (MEA), is “the benefits people obtain from ecosystems” with different classifications dividing them up in provisioning, regulating, supporting and cultural categories , or provA significant driver of ES change is the change in land use . Water aSeveral Mediterranean basins have experienced water shortages in recent decades and future climate change projections foresee further pressure on water resources  as this Agriculture provides, as well depends on, ecosystem services , uses 70% of the fresh water worldwide and is practiced on 40% of the Earth’s land surface and in almost 50% of the European Union territory ,25,32. PThe qualitative and quantitative assessment of ES is usually based on indicators  that canConsidering the increasing pressure on agriculture to sustain food production for the expanding human population under changing climate conditions, new areas suitable for food production will be sought. We assume that the increase of air temperature will influence the hydrologic balance of currently flowing perennial rivers in arid and semi-arid areas that can result in the rise of IRES in the landscape. Thus, greater attention should be paid to this landscape feature and their potential to provide ES should be further studied. Being aware of this research gap, this study presents (i) a review on the importance of IRES and the services they can provide to agricultural landscapes; (ii) a classification tool to assess the impact of IRES to provide ES by agricultural landscape; and this study (iii) applies the classification in order to identify the importance of the intermittent Caia River for its surrounding agricultural landscape.The classification of the ES follows the CICES  classifiNext, IRES impacts to ES within the agricultural landscape were evaluated according to observations from the conducted field monitoring in the study area, which included expertise and evaluation assessment from external professional companies and local agronomists. The impact classification was evaluated throughout a 5-point scale—very positive (++), positive (+), neutral (+/−), negative (−) and not applicable (n/a). The very positive effect meant a significant impact of the ES provided for the agricultural landscape; in the case of a positive effect, the impact was assigned making no distinction among the land use to which the ES was related . The negative impact was identified for the ES which could be negatively impacted by IRES or lost. The neutral effect expressed the spatial (within basin) or seasonal variability of the impact; and the not applicable effect was assigned in the case of an inability to identify the impact.2 and it is located between Portugal and Spain  within the group of regulation and maintenance ES can by affected negatively and, for the same amount of ES, it is not possible to identify the potential impact. Hydrological cycle and water flow maintenance, Flood protection and storm protection are ES provided by both agricultural landscape and IRES. However, their influence by interaction between landscape and IRES very depends on the local conditions. Therefore, we prefer to use the assessment not applicable instead of neutral. The negative effect can occur in the case of the dry phase. The hydrological phase of pools can affect the ES provided by agriculture only positively (76%) or very positively (6%).The comparison of groups of the ES shows that there is a very positive effect mainly for the cultural ES for all IRES stages. It is very difficult to find any information about the negative effect to provide cultural ES. We assume that the flowing phase of IRES can have only a very positive effect on all ES; the dry phase of pools affects one ES positively and neutrally, respectively. In the case of heritage and culture ES, we were not able to identify the impact of IRES.The temporal Caia River is a resource for the irrigation of arable land, given that the amount of available water for crops and orchards can vary due to the presence of riparian vegetation . The strDiscoglossus galganoi), the Iberian midwife toad (Alytes cisternasii), the Bosca’s newt (Lissotriton boscai), and the Schreiber’s green lizard (Lacerta schreiberi) in the Caia River basin [Although the intensive monoculture practices of the region associated with the types of crops grown in the watershed  are well known for reducing biodiversity, carbon stocks and water budgets as a result of maximizing production ,41,42, ser basin , that arThe variety of the river phases—flow, pool and dry—allows for the development of lotic, lentic and terrestrial habitats and affect the migration of terrestrial animals, both wild and domestic, because of insufficient water conditions and nutrition with pools remaining as their only available water source during the drought in the Caia River basin ,31. MigrThe Caia dam is a crucial part of flood protection. It protects not only human properties but also the area itself. On one hand, flooded water can contain important nutrients for agriculture and can increase the soil fertility; but, on the other hand, it can be a source of harmful contents  originating from activities located upstream and accumulating along the river. Without the dam, the permanently irrigated agriculture could not be as intensive during summertime as it is now. A change in crops grown, with lower water requirements and lower transpiration, would be needed. If not, the yearly yield would be lower or none. The intermittency of the river caused by agricultural activities in the area has not yet been recognized. Water uptakes from the river and the dam are regulated, so downstream impacts remain minor.The Caia dam collects water during the winter and spring seasons, when the water flow is higher than the requirements for the delivery the different ES. The collected water is mainly used for human consumption and the irrigation of crops, olive trees, vineyards and orchards. Intermittence within the Caia River occurs naturally upstream of the dam, where unmanaged water withdrawal occurs. However, an insufficient water supply can cause intermittence spreading risk downstream of the dam where most irrigated soils are located. The stressors and pressures on water systems occurring within the Caia River basin comprise (a) water quantity—including flowing water frequency, groundwater abstractions, changes in precipitation, temperature and runoff; (b) water quality—the point and diffuse pollution caused by nutrients, chemicals and heavy metalloids built-up; (c) habitat—hydro-morphological alterations; and (d) biota and biological communities—as invasive species .3 year−1 of water in 6,493.92 ha. Because of the edaphic-climatic conditions of the region, a comparison between the amount of water consumed by spring/summer crops and the actual precipitation reveals a great disproportion that affects the remaining available water for other activities in the area. The average precipitations are able to cover from 43 to 92% of crop water demand. A comparison of land use change between the years 1990 and 2012 shows that agricultural areas decreased by −2.67%, and were replaced by forest and semi natural areas (+1.95%) and artificial surfaces (+0.65%). We also recognized change within the agricultural areas, where the main decrease was observed for non-irrigated arable land (−12.41%) and rice fields (−0.85%). On the other hand, there was an increase in areas of olive groves (+3.12%), pastures (+3.64%) and permanently irrigated land (+2.35%), which can be recognized as land use change, leading to higher water consumption and water demand in general.Acacia spp.  are stressors for the dry riverbed ,62. NutrRetained clay and organic matter as a result of water and wind erosion in the dry riverbed may decrease the total soil and nutrient loss in the area with the developed vegetation of the riverbed also likely to reduce soil erosion . On the Dry channels also play an important role as sinks for floodwater and recharges for alluvial aquifers  that, toSeveral ground-nesting pollinators use the dry riverbed and riparian vegetation for nesting, which increases crop and orchard pollination. The importance of wild pollinators that fly from nesting sites in nearby habitats is documented in .According to , the floRegarding impacts on water quality, treated or untreated wastewater from households, mining or industries can contain a small proportion of nutrients important for the optimal growth of crops. However, heavy metals, bacteria, viruses and other polluting compounds are present as well, with some being harmful for crops or animals. The water quality of the Caia River is mostly affected by untreated wastewater from industries and diffuse pollution from agriculture and animal production, as there are several small companies  in the area contributing to the outflow of untreated wastewater into the river .Nutrients in the surface water have a major impact on water quality  that, deCultural ES are especially well supported by IRES as they increase the area accessibility for anthropic recreational activities such as canyoning, swimming, fishing, and corridors for hikers, bikers, horse riders or motorcyclists. The high recreation value of the Caia River area can be deduced from the fact that 17,664 recreational and 209 commercial fishing licenses were issued within the Portalegre district.Access of heavy machinery to the area may also be improved. Because of allelopathy and competition for resources such as water, nutrients, light and space weeds are synonymous with lower yields or higher production costs and, thus, usually undesired by landowners. Nevertheless, these weeds are an important piece of biodiversity as they can attract more pollinators and, therefore, increase crop pollination, a fact that was observed in the Caia River.From the abovementioned, it is possible to recognize, that most of the ES provided by agriculture could be boosted up by the Caia River. The Caia River itself does not provide ES such as plant-based or animal-based resources of energy, cultivated crops, pollination, pest and disease control or heritage, but without the ES assigned to the intermittent part of the Caia River, those ES could not be created or the potential would be very low.Nonetheless, our work estimated that each hydrological phase of IRES increases the ES provided by the agricultural landscape. The dry phase of IRES has a neutral impact on several ES or is not applicable, at least. Thus, the present study confirms the conclusions of , that IRIn this study, we focused on the benefits provided by the Caia River to the agricultural landscape and on the stressors from the agricultural landscape to the Caia River that may decrease or increase the ES. We identified 10 potential benefits of the Caia River for the agricultural landscape and seven stressors from the agricultural landscape to the Caia River. During the flowing phase, we recognized that 92% of ES can be provided to the agriculture, which can be very positively affected by IRES; but only 15 and 7% in the case of pools and the dry phase, respectively. The comparison of groups of ES shows that there is a very positive effect, mainly for the cultural ES for all IRES stages.Our study estimates that each hydrological phase of IRES increases the ES provided by the agricultural landscape. However, the dry phase can potentially have a negative impact on several services. The intensification of the agricultural sector is the main provision of the water resource within the Caia River basin, but we were able to identify several other ES that were positively impacted.Impacts caused by the Caia River itself and by the smaller, ephemeral, tributaries within the basin should not be excluded from the ecological equation. The present study is in line with the conclusions of other authors that state that IRES should be ecologically and economically valued. Future research may provide relevant insights in order to define the temporal dynamics of ES provided by the different hydrological phases of IRES similarly to the temporal dynamics of the different ES provided by cover crops as published.


Hastisetae are a specific group of detachable setae characterizing the larvae of Megatominae (Coleoptera: Dermestidae), commonly known as carpet and khapra beetles. These setae are located on both thoracic and abdominal tergites and they are the primary defense of the larva against invertebrate predators. According to previous studies, the main purpose of hastisetae is to work as a mechanical obstacle, but they are also capable to block and kill a predator. Hastisetae, single or aggregate, function as an extremely efficient mechanical trap, based on an entangling mechanism of cuticular structures (spines and hairs) and body appendages . It is believed that this defensive system evolved primarily to contrast predation by invertebrates, however it has been observed that hastisetae may affect vertebrates as well. Although information on the impacts of vertebrate predators of the beetles is lacking, hastisetae have been shown to be a possible threat for human health as an important contaminant of stored products (food and fabric), work and living environment. Review of past and recent literature on dermestid larvae has revealed that despite these structures indicated as one of the distinctive characters in species identification, very little is known about their ultrastructure, evolution and mechanism of action. In the present work, we will provide the state of knowledge on hastisetae in Dermestidae and we will present and discuss future research perspectives intended to bridge the existing knowledge gaps. The cuticle plays a pivotal role in several aspects of arthropod biology, representing the interface between the living tissue and the external environment . Thus, tIn order to compile and then review the most exhaustive literature on hastisetae we performed a careful and reiterated research in Google Scholar and Scopus through the use of keywords such as “hastisetae”, “Dermestidae”, “defense”, “larva”, integrated by the usage the Boolean operators AND, OR, NOT and the use of ” ” for specific word combinations. The literature not available online has been recovered thanks to Network Inter-Library Document Exchange (NILDE), a web-based software for the service of Document Supply and Inter-Library Loan, managed by the Italian National Research Council. Our research has enabled the collection of more than a hundred publications, of which ninety were considered in the realization of this review. The library created was comprehensive of literature in English, German and French.Reesa, Trogoderma). In some larvae, the hastisetae give origin to real tufts of hairs located on the posterior corners of the terga IV–VII  or V–VII  (Hastisetae (or hastate setae) have been cited in several papers dealing with Dermestidae systematics , speciesthrenus) . The hasthrenus) . The pedthrenus) . Hastisethrenus) . The shathrenus) . These sthrenus) . The lasthrenus)  Fig. 1)Reesa, Trthrenus) , functiothrenus) . This stthrenus) . The shathrenus)  and possthrenus) . These sthrenus)  and coulthrenus) . Hastisethrenus) .sensuTrinodes (Trinodinae), in which modified hastisetae are described sensuTriescribed . This grescribed , exploitescribed . Megatomed sensu, which ced sensu. These sed sensu favored ed sensu. In a died sensu. In geneed sensu ed sensu The capability to feed on a wide range of food resources scarce in water content and to resist to prolonged starvation makes Megatominae larvae the perfect candidate to inhabit working and living spaces. In addiction, due to their slow movements and cryptic behavior these larvae result difficult to detect and remove. For this reason, some species are now synanthropic and cosmopolitan , having The scant information about the fine morphology and the ecological roles of hastisetae, and their implications in human health opens a whole horizon of research possibilities. Hastisetae morphology is undoubtedly the starting point for any future study. The characterization of hastisetae through electron microscopy and micro-CT is the basic and fundamental step to understand their functional morphology. The identification of specific morphological traits in the hastisetae will help to solve Megatominae systematics, highlighting the evolution of these structures in relation to phylogeny and biology. A detailed knowledge of hastisetae morphology will allow us to understand the defensive mechanism and if it acts similarly in all Megatominae. Comparing reactions of different predators to hastisetae will be useful to evaluate the different effects and particularly if this defensive system is primarily directed towards invertebrates and/or to vertebrates. Are humans or other vertebrates possible targets of hastisetae, and if so what are the causes of the unpleasant side-effects in humans? Is it the penetration of these setae trough epithelia the main cause of inflammation and are there any particular substance inducing the reaction, as it has been showed in Lepidoptera? Chemical analysis of secretions can identify and characterize the compounds responsible of the inflammation in humans and clarify their possible role as adjuvants in defense against the threats. Understanding the causes of allergic responses in humans will allow the development of specific medical therapies. Hastisetae could become an important addition in species identification, with relevant application in forensic entomology and pest management on stored products. Furthermore, the creation of a molecular fingerprint based on hastisetae content can aid in developing tools to detect insect fragments in contaminated stored products, especially food.


Aedes and have caused several outbreaks in world over the past ten years. Morphological identification of mosquitos is currently restricted due to the small number of adequately trained professionals. We implemented a computational model based on a convolutional neural network (CNN) to extract features from mosquito images to identify adult mosquitoes from the species Aedes aegypti, Aedes albopictus and Culex quinquefasciatus. To train the CNN to perform automatic morphological classification of mosquitoes, we used a dataset that included 4,056 mosquito images. Three neural networks, including LeNet, AlexNet and GoogleNet, were used. During the validation phase, the accuracy of the mosquito classification was 57.5% using LeNet, 74.7% using AlexNet and 83.9% using GoogleNet. During the testing phase, the best result (76.2%) was obtained using GoogleNet; results of 52.4% and 51.2% were obtained using LeNet and AlexNet, respectively. Significantly, accuracies of 100% and 90% were achieved for the classification of Aedes and Culex, respectively. A classification accuracy of 82% was achieved for Aedes females. Our results provide information that is fundamental for the automatic morphological classification of adult mosquito species in field. The use of CNN's is an important method for autonomous identification and is a valuable and accessible resource for health workers and taxonomists for the identification of some insects that can transmit infectious agents to humans.Dengue, chikungunya and Zika are arboviruses transmitted by mosquitos of the genus  Arthropod-borne viruses are responsible for more than 100 of the diseases that comprise the estimated global burden of communicable human diseases. Dengue,Aedes aegypti and Aedes albopictus have received worldwide attention since both species are efficient vectors for the transmission of human arboviral diseases, such as Zika, dengue, chikungunya, and yellow fever[Culex could be a possible vector of the Zika virus[Ae. aegypti, Ae. albopictus and C. quinquefasciatus are very common domiciliary mosquito vectors that are present in almost all urban areas in Brazil[Ae. aegypti, Ae. Albopictus are, among all Aedes species, the ones that circulate in endemic areas. Furthermore, Aedes mosquitoes have been demonstrated to be capable of transmitting Zika and other viruses in many tropical areas in the Americas, Africa, and Asia[low fever,8,9. Addika virus–12. Ae. in Brazil. Ae. aeg and Asia.Entomological characterization is fundamental for acquiring information about mosquito behaviour. In general, the current procedure used to identify the species of an insect requires an individual visual examination of the insect, which is time consuming and requires several years of experience,15. WhilAnother possibility for species identification is the use of molecular techniques that have been validated by various studies, such DNA barcoding, environmental DNA testing and real-time PCR (qPCR)–23. HoweRecently, new models that facilitate the automatic classification of mosquitoes have been developed. Some studies have attempted to classify mosquito species based on the frequency and harmonics of their wingbeats,25. TechWingbeat vibration techniques have been reported to demonstrate a high accuracy in the classification of mosquitoes. HoweverWithin the field of image feature analysis, studies have been conducted to identify mosquitoes according to their life cycle stage . Some studies have attempted to automatize the process of egg counting to assess the level of fecundity and thereby estimate the mosquito population size and conduct morphometric analysis–38. StudAedes mosquito larva using a small dataset; when 200 epochs were used, the network achieved 96.8% accuracy[Deep learning methods are essential for the processes underlying general object recognition. In 2012 accuracy.Aedes mosquito species is essential for both the recognition of the vectors involved in disease transmission and the development of fast and efficient control strategies[Ae. aegypti, Ae. albopictus and C. quinquefasciatus. As showed, this tool would be very useful to reduce the time, to allow its use by less experienced expert and to capture preserved features of the body characteristics of the mosquito. Another objective of this work is to initiate a preliminary scientific study that would allow the community be part of the control of vector-borne diseases.It should be emphasized that correct identification of adult trategies. In thisConsidering that the selection of algorithm training parameters is essential to improve the accuracy and reliability of the method, this study also applied the statistical analysis prior to the selection to determine the parameters set to be used to classify the mosquitoes.No permits were required for sampling for this study. The field sampling did not involve any endangered or protected species.Ae. aegypti mosquitos . The capture of adult insects in the field resulted in the collection of 73 specimens of Ae. aegypti, 94 specimens of Ae. albopictus and 110 specimens of C. quinquefasciatus.The mosquito samples used for image capture were obtained from the Parasitology Laboratory of the Federal University of Bahia–UFBA  and were also collected in the field. The samples obtained from UFBA were The field sampling took place between September and October 2017 in the city of Salvador in two collection areas . CDC light traps and suction tubes were used for the collection of adult insects.The captured specimens were euthanized with ethyl acetate and stored in entomological collection tubes until identification was performed by an entomologist.Ae. aegypti, Ae. albopictus and C. quinquefasciatus species. In addition, differentiation of males and females was conducted as described in a previous study[A robust, correctly structured dataset was created to allow the differentiation of the ous study. A modelThe images in the dataset were extracted from the ImageNet platform and were also photographed with various cameras, including a Leica DMC2900  coupled to a stereoscopic Leica M205C at the Oswaldo Cruz Institute of Entomology at FIOCRUZ (Rio de Janeiro–Brazil), a Canon Power Shot D30  coupled to a Wild M3C stereomicroscope  at SENAI CIMATEC  and Samsung J5  and Apple iPhone 7  mobile phone cameras. The images were collected at different resolutions and levels of quality to develop a classification method that utilized a wide range of images to prevent possible overfitting of the trained model. An average of 10 photographs of each specimen were taken at different angles and proximities.Once the dataset was structured and the images acquired, the number of images to be used for training, validating and testing the model was determined. The application images were those that we intended use for the classification of mosquitoes after the model was developed. This was done to allow the model to be used by any person, not only a specialist using a microscope, who is able to photograph an insect and then run the model to classify mosquitoes.Ae. aegypti photographed using a digital camera  and should have been taken with a mobile phone. l camera  and mobil camera .For the testing phase (phase 3), images were extracted from the dataset and used only after the model was validated. Additionally, the images used for testing were not used to train or validate the model. This was done to avoid research bias and minimize the chance of overfitting.C. quinquefasciatus female class was the class with the smallest number of application images (70 images), fourteen images (20%) from each of the other classes were randomly removed from the dataset. Python scripts were employed to randomize the chosen images.To standardize the analysis of the results, the test dataset contained the same number of images from each of the six classes of mosquitoes. It was decided that the number of images corresponding to 20% of the number of images in the smallest class would be used for testing for all classes. As the Within the references used in this work, no consensus was found concerning the ideal dataset distribution between the training (phase 1), validation (phase 2) and testing (phase 3) phases.To determine the best image distribution for training and validation, once the test sample size was already defined, the percentage of application images used in the training phase was defined as a factor, varying in four levels , in a full factorial experiment. The objective was to evaluate statistically the best distribution of application images between the training and validation phases that would present the best classification accuracy for the intended application in entomology.We used nVidia DIGITS software  with a NVIDIA GeForce GTX TITAN GPU for processing. We used the software on the Linux Ubuntu operating system LTS Distribution 16.04 . The Caffe framework was used for the LeNet,43, AlexFor a long period, LeNet was considered the state of the art of Artificial Neural Networks (ANN's). LeNet was one of the first ANN's used to improve the original backpropagation algorithm; the remarkable development of this well-known network was the first step towards the application of the Deep Learning method.In 2012, Alex Krizhevsky released AlexNet, which was a deeper and much wider version of the LeNet that won, by a large margin, the difficult ImageNet competition. AlexNetInception, later named GoogLeNet). This neural network was the winner of ILSVRC 2014, surpassing AlexNet, and was proclaimed the new paradigm for convolutional neural networks.In 2014, Christian Szegedy, from Google, began to investigate methods to reduce the computational burden of deep neural networks. In doinThe CNN algorithms requires the definition of several parameters prior to the training phase. Depending on the application, these parameters might have more or less influence on the classification results. Prior random tests were performed to understand which set parameters have more influence and should be statistically analysed as a factor in the full factorial experiment in order to stablish the best value. Other parameters with less influence on the results were set as default in the algorithm.Number of epochs and Seed were parameters defined as a constant value. The prior random tests showed that 200 epochs are enough to stabilize the training and validation phases. In case it generates overfitting it would be easily identified. Define the seed as a constant value was important to standardize the neural network weights initiation for all CNN and also, for each time we run the algorithm. The parameters evaluated in the full factorial experiment were: percentage of the application image used in the training phase; solver algorithm; the learning rate (LR); and learning rate decay function. The other parameters, such as the batch size, batch accumulation, learning rate step size, learning rate power, learning rate gamma, crop size and mean subtraction, were set according to pre-defined default for each network.To understand the influence of each parameter and their correlations with one another, full factorial experiments were conducted using the Minitab 17 software . The parameters used as the inputs for the full factorial experiments are shown in Using the Minitab software, we created an experiment with four factors: the percentage of application images used at training, solver algorithm, learning rate, and LR decay function. The number of epochs and the seed was fixed. For the experiments, we defined the number of levels as shown in Based on the result of the factorial experiments, it was calculated that 192 experiments should be conducted on one of the three convolutional neural networks. The output variables to be evaluated were the percent accuracy during the validation phase, loss function and percent accuracy during the testing phase.Based on the full factorial experiments, GoogLeNet was the network selected for conducting the 192 planned experiments.The first step in the analysis was to interpret the statistical significance of the parameters that were used  and their relationship with the results. The ‘P value’ was calculated to evaluate the statistical significance of the parameters and the effects of their interactions on the outcome of the experiments.The best performance obtained for each outcome was then defined as the target value for optimization analysis and was used to determine the best combination of parameters. These combinations were used to train the other two convolutional neural networks, LeNet and AlexNet.The species and gender of each of the dataset classes used to classify the 4,056 images are shown in st level analysis) on the accuracy of the testing phase (phase 3). In this analysis, the use of the solver algorithm ‘3’ (Adam) and a learning rate of ‘3’ (0.1) significantly reduced the accuracy of the mosquito image classification. However, a learning rate of ‘1’ (0.001) was an important parameter that was used . Almost every parameter had a significant influence on the results of the performance of the trained neural network , with the exception of the interaction between ‘% application images (train) * Solver’ and ‘% application images (train) * LR Decay Function’ .nd level analysis) on the interaction of the parameters with one another. It is clear that a learning rate of ‘3’ (0.1) reduced the accuracy of the testing phase when combined with any of the other parameters. Consequently, this learning rate should not be used subsequent analysis. It was also confirmed that the solver algorithm ‘3’ (Adam) reduced the accuracy of the testing phase. However, the combination of a learning rate of ‘2’ (0.01) with solver algorithm ‘4’ (AdaGrad) obtained better results than the combination of a learning rate of ‘1’ (0.001) with the same solver algorithm . Overall, the learning rate of ‘1’ (0.001) produced the best results.To define the best set of parameters, an optimization function was calculated in Minitab that set the target values for each outcome. The best parameter combination was obtained in the 4-2-1-3 set, which resulted in the use of 60% of the application images during training . Therefore, this parameter set was used for the subsequent training of all three convolutional neural networks.The LeNet neural network achieved an accuracy of 57.5% for the classification of mosquitoes . InteresC. quinquefasciatus in the validation phase in terms of the loss function after 200 epochs, GoogLeNet demonstrated the best performance for the classification of adult mosquitoes.With the exception of its performance during the classification of Aedes and Culex genera, an accuracy of 96.4% was obtained. Another important outcome was the performance in the classification of Aedes females, during which an overall accuracy of 82.1% was achieved.It is also relevant to evaluate the classification performance for the different genera of mosquitoes. For the classification of the Ae. aegypti and Ae. albopictus species in the field. Members of the genus Aedes are well-known carriers and disseminators of arboviruses[C. quinquefasciatus mosquito in our study because its medical importance as a vector for some arboviruses associated with the recent explosive epidemic occurred in Brazil[Culex sp. to transmit Zika virus has not been confirmed by recent studies[To the best of our knowledge, this is the first study that uses convolutional neural networks (CNN's) to extract features from images of adult mosquitoes to identify boviruses,13,44,45in Brazil,12. Howet studies,46.Aedes larva identification. The algorithm showed excellent performance, with 100% accuracy, in the identification of Aedes larva; however, for other mosquito species, the misclassification rate was 30%. Additionally, the sample size used in this study was tiny. Although their review have a significant scientific contribution, it requires the use of laboratory equipment and do not address issues such as time and logistics required in the traditional classification method for capturing and analysing the samples.Sanchez-Ortiz et al. used a vAedes mosquitoes from other mosquitoes correctly. Our method was able to achieve 100% accuracy in classifying between Aedes and Culex, although Culex was misclassified as Aedes 10% of the time during the test phase. In the recognition of the Aedes female, which is the most important vector of arboviruses, we achieved 82% accuracy. It is essential to understand that it is a training process and every time we add a new species further training of the network will be necessary.In our work, we used over 4,000 mosquito images in this preliminary study of the use of CNN's for the identification of mosquitoes; with such a small sample size, we achieved an accuracy of 76.2% in the automatic recognition of species and gender for six classes of mosquito. However, it is very promising that we were able to distinguish The importance of insects to transmit human diseases have motivated researchers to develop an arsenal of mechanical, chemical, biological and educational tools to help mitigate the harmful effects of insects. Batista et al. reinforcTaxonomists have been searching for efficient methods to meet real world insect identification requirements. The corCulicidae subfamily, which was the object of our study. Furthermore, molecular identification, although generally accurate, is costly and often impractical. Other disadvantages of molecular techniques are the high cost and time applied in the laboratory. In this way, developing countries, which are often the main endemic areas, do not have sufficient resources for investments in laboratories with high technologies.Unfortunately, as mentioned previously, taxonomic identification of mosquitoes is a time-consuming and challenging process that requires trained specialists. The high variability also compromises this method of identification of the morphological and molecular characteristics found in members of the Although there is progress in autonomous identification systems for insects, two inadequacies remain. First, some systems obtain high accuracy of identification for limited insect species but have very narrow functionality, because the source code for those computer programs must be rewritten when these types of system are tested with new morphological insect data. Second, some systems, can be used to identify different taxonomic groups of insects, but the accuracy is not sufficient due to high variations during processes of digitizing morphological features and insufficient powerful classifiers which only can search local optimizing solutions rather than the global optimizing solutions during computation.Autonomous identification method could be valuable and more accessible to health workers and other non-taxonomists for use in the identification of insects that can transmit infectious agents to humans. Herein, we demonstrated that it is possible to use a CNN to analyse photographic images to identify and classify mosquitoes by species and gender.When adequate data are available, many methods, such as the Support Vector Machine (SVM) and Tangent Distance Classifiers (TDCs), can achieve good accuracy in automatic classification. In a reAedes wings and larva, Lorenz et al.[Anopheles, Aedes and Culex genera to test the hypothesis that classification based on wing shape characteristics using an Artificial Neural Network (ANN) was more accurate than traditional classification using discriminant analysis. The ANN was able to correctly classify species with greater accuracy than the conventional method using multivariate discriminant analysis, with an accuracy varying from 86% to 100%. However, this study focus on parts of the body of the mosquito and requires the use of laboratory equipment.In another application of a convolutional neural network for the identification of nz et al. used 17 Another challenge in the use of convolutional neural networks for image recognition with a limited number of images is the risk of overfitting. Application of different sets of images during the training, validation and testing phases may reduce the risk of overfitting. AdditioAnother possible way to increase the reliability of our neural network for the identification of mosquito images is to re-design the layers of the neural network to include additional morphological characteristics, such as wing shapes, palps and other features.Anopheles and other species among the 3,556 species of Culicidae that are currently recognized.This preliminary study is an opportunity to construct a dense dataset of images of mosquitoes that can transmit diseases to humans, including The final goal is to embed the model in a mobile APP that will allow for community participation and thereby facilitate efforts to control vector borne diseases.Aedes females.This work demonstrates that CNN's can be applied to the autonomous classification of mosquitoes to aid in the screening of possible vectors of arboviruses by health workers and other non-taxonomists. High accuracy of classification of mosquitoes using CNN's can be achieved using different neural networks. LeNet and AlexNet had inferior performances to that of GoogLeNet, which indicates that the use of more complex networks with more layers is necessary to improve accuracy. Taxonomic classification of insects can be performed automatically via the acquisition of image's features that differentiate one insect from another. Only by using both the genus and sex we achieved high accuracy in the identification of Our results provide information that is fundamental to the automatic morphological classification of a species of interest applying CNN to classify the adult mosquito in the environment it lives. In the critical discussion, the published works develop mainly a laboratory tool. In the taxonomy of adult mosquitoes, an epidemiological classification has a different implication. The application method we propose will be a robust epidemiological instrument for the rapid identification of focus of mosquitoes allowing the community to be part of the control of vector-borne diseases.Another essential contribution relies on the construction of a mosquito dataset. Much data is required to increase the reliability of any autonomous method to recognize objects. This study already provides more than 4,000 mosquito images, which is vital in creating a significant and robust dataset for later applications.We hope that later, the model can be embedded in a mobile APP to allow for community participation and thereby facilitate efforts to control vector borne diseases. Indeed, this model can be used to improve vector control operations that are linked with fast and reliable identification of targeted species and to provide knowledge of their biology and ecology.


Approximately 23% of Americans over age 12 have some level of hearing loss.In this account, the authors reflect on the successful experiences of a visiting DHoH medical student in an academic EM rotation at a Level I trauma hospital that serves a diverse population, and they identify the potential challenges for DHoH students in an EM setting, offer solutions including reasonable accommodations, and provide commentary on the legal requirements for providing full and equal access for DHoH students. We secured permission from the student to share the contents of this article prior to publication. Deaf and hard-of-hearing (DHoH) individuals6Researchers suggest that the inclusion of DHoH students, residents and physicians in the medical education continuum could offer multiple benefits to peers and patients alike including increasing disability awareness, improving interactions with DHoH patients and family members;15all physicians through (1) a focus on accurate translation,25While reduced healthcare disparities for patients and a commitment to social justice should drive the inclusion of DHoH students in medicine, recent court decisions have supported qualified DHoH individuals in the healthcare workforce noting that DHoH individuals are appropriate providers when properly accommodated.A deaf medical student completed a one-month visiting rotation in EM at a medical school in the Western U.S. The student had a history of using hearing aids, cochlear implants, communication access real-time transcription (CART), Cued Speech transliteration, and ASL interpreters . With apThe student applied to the EM rotation through the Visiting Student Application Service. Once accepted, and two months prior to the start of the rotation, the student notified the school of the need for accommodations. The student’s designated interpreter contacted the institution’s Americans with Disabilities Act (ADA) designee to request accommodations and to provide guidelines and guidance for working with a deaf student. Two weeks prior to the start of the program, the program director and disability director provided a brief educational outreach to the ED staff, including techniques for working with deaf students in the clinical setting. The student and DI were invited to share their insights about working in the department at the conclusion of the rotation.The ED setting presents challenges for all students, specifically a fast-paced and stressful working environment, interacting with patients speaking multiple languages, tight and noisy working spaces, witnessing trauma and overall loss of control in emergency situations. Yet the deaf student’s feedback about the rotation was positive. The student and the DI noted the inclusiveness of the experience in this environment, including a respectful, responsive and communicative team. For example, hospital staff directly approached the student, not the DI, when they had questions about communication . Educational materials and experiences for students in the program were equally accessible for the deaf student, and the program expressed genuine interest and excitement regarding the diversity the deaf student brought to their program.The program director welcomed the student and set clear expectations for the ED team. The DI was included in every interaction from orientation to patient care. Access to orientation items and to the virtual learning platform were completely accessible as a result of being addressed proactively with the program director, student coordinator, disability services office, and designated interpreter. By requesting accommodations and accessible materials two months in advance, the student ensured 1) the addition of captioning to instructional videos contained in online learning platforms, 2) complete scheduling of the DI for didactic and clinical activities, and 3) the development of specialized medical sign language for the rotation (for terminology not currently designated in ASL) in advance of the student’s arrival. This collaborative approach facilitated access to the program, normalized the presence of a deaf student, and contributed to an inclusive and non-marginalizing experience. Once the rotation began, the student identified potential barriers to the rotation including having to use a phone for consults, learning new clinical skills under traditional instructional models, responding to codes, and navigating field experiences, all of which could be removed using accessible practices. Each area is addressed below.While phone calls in the ED were a challenge for the student, these barriers were easily addressed. For this rotation, the phone was frequently used to access the language interpreting line, consult with the pharmacy, specialist physicians, and the laboratory. To facilitate phone calls, the student used assistive devices including adaptive headsets and video relay service. A speakerphone function or a two-way headset was the chosen method for facilitating phone calls, with the DI on each call interpreting for the student. This was a productive and effective method for removing barriers in this setting. A quick and professional disclosure that the student was using an interpreter or relay service reduced potential confusion when the student’s gender did not match the voice of the DI, or if the receiving party was unfamiliar with communicating with a deaf person.The acquisition of procedural skills is an essential part of any rotation. Standard EM procedures range from laceration repairs and venipuncture to central line placement and endotracheal intubations. The traditional model of “see one, do one, teach one” whereby students watch a demonstration of a procedure, practice a mock simulation, and then demonstrate competency to a preceptor needed to be modified for the student. Typically, when demonstrating a procedure, the spoken instructions and demonstration often occurred concurrently. For a deaf student, it is difficult to simultaneously focus on both the procedure and the interpreter to capture the instructions. In these situations, the student felt empowered to request that faculty discuss the procedure first, followed by a demonstration of the procedure to allow the student to view the interpreting of instructions before shifting to the demonstration. Allowing time for verbal instruction in advance of demonstration was necessary for the deaf student to have full access to the material. While this approach to teaching the material is necessary for the deaf student it can also increase retention for all students by tapping into multiple learning styles.During a code, communication is essential to ensure role expectations and the team’s approach to the case. When a deaf team member participates in the code they can easily follow their assigned role under the direction of the DI. Additionally, when deaf students become physicians and run a code they can develop strict communication protocols, ensuring that each team member understands designated hand signals. During this rotation, the student and the DI participated in several codes without incident. For each code, interpreter positioning was quickly identified and a line of sight was established to facilitate the student’s involvement and interaction with the code.As part of the rotation, the student was expected to complete a ride-along with emergency medical services (EMS). Excusing the student from field experiences had been the approach during other rotations; however, this program felt strongly that the student should engage in all aspects of the rotation and that the rotation should be fully accessible. The student and the DI were included in required field experiences, including the ride-along in the ambulance. Observing the EMS crew was the main learning objective of the experience. However, the crew was called to an acute incident during the ride-along that necessitated an all-hands-on-deck approach. The student was included in the response by using non-verbal communication  and by handing appropriate supplies and pointing or guiding the student’s hands to the needed medical procedure. The DI facilitated verbal communication by establishing a position near the paramedic and emergency medical technician and interpreting essential instructions to the student.The ADA was amended effective January 1, 2009, and new ADA regulations took effect March 15, 2011.A number of methods exist that allow for the full inclusion of DHoH students in medical education including ASL interpreters, DI, Cued Speech transliterators, and adaptive hearing devices. DHoH students with appropriate accommodations, including assistive technology, are able to effectively follow procedural instructions, respond to codes, and respond to other environmental cues effectively, even though these tasks are communication-dependent.Given the large number of people with hearing loss that affects communication access, it is critical that the growing number of DHoH physicians in the pipeline be well trained and positioned to provide effective, culturally sensitive care. This is especially critical when navigating the communication challenges in EM environments. As evidenced in this case study, the logistical hurdles to access for a deaf student in an EM rotation, and for DHoH students broadly, can be remedied with creativity, advanced planning, and the institutionalization of team-oriented learning environments that prioritize clear communication.