Over the last decade trauma services have undergone a reconfiguration in England and Wales. The objective is to describe the epidemiology, management and outcomes for liver trauma over this period and examine factors predicting survival.Patients sustaining hepatic trauma were identified using the Trauma Audit and Research Network database. Demographics, management and outcomes were assessed between January 2005 and December 2014 and analysed over five, 2-year study periods. Independent predictor variables for the outcome of liver trauma were analysed using multiple logistic regression.4368 Patients sustained hepatic trauma (with known outcome) between January 2005 and December 2014. Median age was 34 years (interquartile range 23–49). 81% were due to blunt and 19% to penetrating trauma. Road traffic collisions were the main mechanism of injury (58.2%). 241 patients (5.5%) underwent liver-specific surgery. The overall 30-day mortality rate was 16.4%. Improvements were seen in early consultant input, frequency and timing of computed tomography (CT) scanning, use of tranexamic acid and 30-day mortality over the five time periods. Being treated in a unit with an on-site HPB service increased the odds of survival .Our study has shown that being treated in a unit with an on-site HPB service increased the odds of survival. Further evaluation of the benefits of trauma and HPB surgery centralisation is warranted. In 2010, there were 5.1 million deaths from injuries  . The per(NCEPOD) study “Trauma: Who Cares?” reporting that more than half the 795 patients examined were subjected to less than good practice [Alongside advances in the management strategies for injured patients has been the realisation that regional trauma systems and centralised trauma units save lives, from literature from the USA , 15 and practice . There wpractice .The objective of this study is to describe the current demographic profile, epidemiology and management of hepatic trauma in England and Wales in a contemporary series from 2005 to 2014, a decade spanning reconfiguration of trauma services.The Trauma Audit and Research Network (TARN) database was interrogated for data on patients coded as hepatic trauma. Hepatic trauma patients were defined as those sustaining any of the Abbreviated injury scale (AIS) codes 5418: 10, 12, 14, 20, 22, 24, 26, 28, 30, 40 and 99. TARN is a collaboration of hospitals from England, Wales and The Republic of Ireland, with some membership in continental Europe. TARN is the largest trauma registry in Europe, with more than 500,000 separate patient records. TARN aims to collect and analyse clinical and epidemiological data and thereby provide a statistical base to support clinical audit, to aid the development of trauma services and to inform the research agenda. TARN began in 1989 and has grown from an initial group of 13 hospitals to 100% of trauma receiving hospitals across England and Wales.Patient inclusion was based on all those patients over 16 years of age coded as hepatic trauma who either: had a length of stay greater than 3 days, were admitted to an intensive care area, died or were transferred for specialist care. Patients with known outcome only were included. TARN excludes all simple isolated limb injuries and isolated fractured neck of femur/pubic ramus in patients aged >65 years. Patients meeting the above criteria were initially identified in the accident and emergency department and followed up by a local TARN co-ordinator who collected details on patient demographics, type and mechanism of injury, haemodynamic stability on presentation, injuries sustained, management and outcome. Injuries were described and scored using the Abbreviated Injury Scale (AIS) 2005 revision described by the Association for the Advancement of Automotive Medicine.Patients who presented over a 10-year period were studied (January 2005–December 2014) in terms of demographics, mechanism of injury, clinical status on arrival and management. Outcome at 30 days was analysed. Five chronological 2 year periods were examined in detail; 2005–2006, 2007–2008, 2009–2010, 2011–2012 and 2013–2014.Data validation and quality assurance was achieved as previously described . BrieflyP values of less than 0.05 were considered statistically significant. All analyses were undertaken using SPSS software, version 16. Independent predictor variables for the outcome of liver trauma were analysed using multiple logistic regression. Overall model fit assessment was with the Hosmer and Lemeshow (goodness of fit) test.Differences between patient subgroups were tested by using the Chi square test, Fisher’s exact test and Mann–Whitney tests. Two-tailed Of 211,934 total records in the TARN database between January 2005 and December 2014, 4697 patients sustained hepatic trauma with 4368 (93%) having a known, recorded outcome. Results are based on the 4368 patients with a known outcome. Median age was 34 years (interquartile range 23–49). Gender distribution remained unchanged during this period, with 3094 (71%) patients being male. In each year of the study over 50% of injuries were due to road traffic collisions. The mechanism of injury for the overall series is shown in Table n = 241) required a liver specific operation, including liver packing, a repair of liver laceration or liver resection. 60% of patients were admitted to critical care (n = 2619) with a median length of critical care stay of 4 days (IQR 2–10 days). Median length of hospital stay was 9 days (IQR 5–20). Demographics, management and outcomes for isolated liver injuries as compared to those injuries sustained as part of a polytrauma are shown in Table 3581 (82%) patients underwent computed tomography (CT) scanning as part of their work-up. Median Time to CT was 1 h (IQR 0.48–2.27 h). 2861 (65.5%) of patients were reviewed by a consultant in the emergency department. Tranexamic acid was given in the emergency department in 21.3% of cases (932 patients). 56% of patients underwent some kind of operative intervention but only 5.5% of patients . The over-all mortality rate in this series of 16.4% compares favourably to the other UK (Scottish) based series reporting outcomes over the period 1992–2002 . In TaiwTrends toward the non-operative management of blunt hepatic trauma have been widely documented , 22, 23 Our study has shown that being treated in a unit with an on-site HPB service increased the odds of survival. There is an improvement in risk adjusted mortality over time which disappears when the logistic regression model includes care in a HPB centre, therefore the observed improvement over time can be attributed to increased exposure to specialist HPB care. The mechanism whereby improved outcomes are associated with increasing HPB specialisation and centralisation in high volume centres may include: HPB surgeons having experience in complex haemostatic techniques that are not routinely used by others; training in vascular and transplant surgery; and detailed understanding of the complexities of liver anatomy. Other factors, such as recognising the need for experienced and early assistance and familiarity with managing post-operative complications (such as bile leaks) also likely contribute. Moreover, institutional factors, such as on-call interventional radiology and endoscopy, experienced theatre and nursing staff greatly contribute to the volume-outcome effect in hepatobiliary surgery . One imp®) principles. The remaining 11% of patients may have warranted an immediate laparotomy due to haemodynamic instability or peritonitis, as recommended in other trauma practice management guidelines [Chronological improvements in management found in this study included promptness of CT scanning and increased use of tranexamic acid. Our series reported the highest rate of CT scanning in 2013–2014 88.9%). Recommendations on the use of CT for hemodynamically stable patients are well established according to Advanced Trauma Life Support  and trained independent coders with stringent validation procedures. The series focussed on a time period where rapid changes were occurring to trauma service provision and HPB services in the UK. Liver trauma outcomes are favourable in the face of this evolving change. Further broad-based analyses comparing trauma outcomes prior to and after the formal accreditation of major trauma centres (MTCs) in 2010 and 2012 are also required to gain an appreciation of the changes that these have achieved. Thus far, significant improvements in the proportions of patients discharged with a good recovery (compared to disability) have been recorded  but overIn summary, our series of over 4000 patients with hepatic trauma indicates that UK mortality rates are comparable to other large international series. Increased exposure to specialist hepatopancreatico-biliary teams in major trauma cases has improved outcomes for hepatic trauma in England and Wales over this decade.


To provide evidence for quantitative magnetic resonance (qMR) biomarkers in Duchenne muscular dystrophy by investigating the relationship between qMR measures of lower extremity muscle pathology and functional endpoints in a large ambulatory cohort using a multicenter study design.2) in lower extremity muscles of 136 participants with Duchenne muscular dystrophy. Measures were collected at 554 visits over 48 months at one of three imaging sites. Fat fraction was measured in the soleus and vastus lateralis using MR spectroscopy, while T2 was assessed using MRI in eight lower extremity muscles. Ambulatory function was measured using the 10m walk/run, climb four stairs, supine to stand, and six minute walk tests.MR spectroscopy and quantitative imaging were implemented to measure intramuscular fat fraction and the transverse magnetization relaxation time constant , although measures in other rapidly progressing muscles including the biceps femoris (|ρ| = 0.63–0.73) and peroneals (|ρ| = 0.59–0.72) also showed strong correlations. Quantitative MR biomarkers were excellent indicators of loss of functional ability and correlated with qualitative measures of function. A VL FF of 0.40 was an approximate lower threshold of muscle pathology associated with loss of ambulation.Lower extremity qMR biomarkers have a robust relationship to clinically meaningful measures of ambulatory function in Duchenne muscular dystrophy. These results provide strong supporting evidence for qMR biomarkers and set the stage for their potential use as surrogate outcomes in clinical trials. Duchenne muscular dystrophy (DMD) is a severe, progressive muscle wasting disorder. Encouraging new approaches for treatment are transitioning from preclinical investigation to clinical trials. Therapeu1H magnetic resonance spectroscopy or chemical shift-based imaging techniques.[2) is sensitive to several pathological features of DMD including fat infiltration, muscle damage, and inflammation/edema.[2 are reproducible from day-to-day and between study sites,[Quantitative magnetic resonance (qMR) measures of muscle pathology are emerging as potentially powerful, noninvasive biomarkers for use in clinical trials for DMD. Muscle fchniques.–10 The Mon/edema.–13 Both dy sites, can diffdy sites,,12,15,16dy sites,,17–19 andy sites, making tImagingDMD cohort, consisting of participants enrolled in a natural history MRI study at three sites in the US, is unique in its size and comprehensive characterization of both functional ability and muscle pathology using qMR measures and is well-suited for a careful analysis of the association between function and MR measures. As such, the objective of this study was to determine the cross-sectional relationship between qMR biomarkers of lower extremity muscle pathology, specifically MRI T2 and muscle FF, and functional outcomes in a large, primarily ambulatory cohort of individuals with DMD enrolled in the multicenter ImagingDMD study. Second, this study examined the association between qMR measures and sentinel events, including loss of ambulation.One of the gaps in the establishment of qMR biomarkers in DMD, and its acceptance by regulatory authorities, is a thorough investigation of their relationship with clinically meaningful outcomes.–22 InitiImagingDMD observational study . Participants had a genetically confirmed diagnosis of DMD and showed clinical symptoms before 5yrs. They were required to walk independently >100m and climb four stairs at study entry. Exclusion criteria included contraindications to MRI, unstable or confounding health issues affecting muscle function, and/or an inability to comply with testing. Beginning September 2010, participants visited the study sites for baseline MR and functional data collection, and participants returned every 12 months for up to four years of follow-up. The Institutional Review Board approved this study at each site . Informed written consent was obtained from the parent/guardian prior to participation, and assent was obtained from the participant.Participants with DMD (baseline ages 4–14 years) enrolled in the longitudinal, multicenter ImagingDMD study, each imaging site completed a standardization process using phantoms and a manual of operating procedures. This process, as well as detailed MR data acquisition methods for this study, have previously been described and reproducibility established.[1-weighted 3D gradient-echo image acquisition, single voxel 1H MR spectroscopy was used to quantify intramuscular FF in the vastus lateralis (VL) and soleus (SOL). Spectra were acquired using stimulated echo acquisition mode (STEAM) with TR = 3,000ms, TE = 108ms, 4 phase cycles, and 16 acquisitions, which were averaged after excluding outliers.[1 and T2 relaxation.[2 data were acquired using a T2-weighted spin-echo sequence with 7mm slice thickness and TR = 3,000ms. Using a monoexponential decay model, T2 maps were created from 40, 60, 80, and 100ms TEs.[2 was determined by tracing the medial gastrocnemius (MG), SOL, tibialis anterior (TA), tibialis posterior (TP), peroneal group (peroneus longus and peroneus brevis—PER), VL, biceps femoris long head (BFLH), and gracilis (GRA) on T2 maps from three contiguous slices. For each muscle, the reported T2 is the mean T2 from the three slices. MRI muscle tracing was performed at a single institution (University of Florida) by analyzers who underwent a standardized training and certification process. 2 maps, MR spectroscopy voxel placement, and 1H spectra from participants with different degrees of muscle pathology.Prior to initiating the ablished.,14 Brieflaxation. MRI T2 d00ms TEs. MRI T2 wAfter MR data acquisition, participants performed the supine to stand (STS), 10m walk/run, four stair climb, and six minute walk tests (6MWT), which are commonly used in natural history studies and clinical trials.–31 For t2, 5.5% for MRS FF, and 6.6% for functional tests). Reasons for invalid MR data included artifacts due to excessive motion and signal inhomogeneity. Statistical analyses were performed using R version 3.2.3. For all analyses, participant data were included from the initial visit as well as any subsequent visits in which the participant retained the ability to complete the functional task of interest. Additionally, the first visit in which a participant could no long complete a functional task was included. Therefore, participants who participated across multiple years had MR and functional data from multiple visits included. Although all analyses are cross-sectional in nature, inclusion of data from multiple years of participation allowed for analysis of a more comprehensive data set and for analysis of sentinel events. Data were analyzed using nonparametric statistics due to not meeting criteria such as independence of samples. To appropriately quantify uncertainty , a nonparametric bootstrap of data with resampling of participants, not individual data points, was used with 1000 samples.[MR and functional data underwent quality assurance by one or more expert reviewers. Missing and invalid data were excluded from analysis  curve was calculated, again with bootstrap confidence intervals.ImagingDMD cohort consisted of 136 participants with DMD. Two enrolled participants were unable to complete assessments at their initial visit and discontinued the study. Cohort characteristics are presented in ImagingDMD cohort studied was young and highly functional at the initial visit with a mean age of 8.3 years (range 4.8–14.6) and with all participants able to ambulate and climb stairs per inclusion criteria. On average, participants completed the timed tests in six seconds or less and walked more than 350m on the 6MWT. Additionally, upon study entry, the mean VL FF of the cohort was below 0.2 and mean VL T2 was <50 ms (min = 35.4 ms).At the time of analysis, the ImagingDMD database. Over the course of the visits, 35 participants lost ambulation, while 48 and 61 lost the ability to climb stairs and complete STS, respectively. Considering data from all visits, muscle FF and MRI T2 values generally increased from year to year, with FF and T2 from proximal muscles such as the VL and BFLH increasing more than that of distal muscles. Quantitative MR data at baseline and 12 months follow-up from a large subgroup of this cohort (n = 109) have been recently presented in detail,[In the cohort studied, participants averaged >four longitudinal visits, and 84 individuals had a total of five visits resulting in 554 visits in the n detail, and a co2 measures, the strongest correlations to functional performance were found for the VL, BFLH, and PER, with correlation coefficient values ranging from 0.70 to 0.78 for timed tests and -0.59 to -0.68 for the 6MWT. Based on MR spectroscopy, VL FF (|ρ| = 0.68–0.78) was more strongly related to functional endpoints than SOL FF (|ρ| = 0.58–0.66). VL FF and MRI T2 correlations with functional measures were very similar. Globally, MR measures correlated more strongly with the STS, 10m walk/run, and four stair climb tests than the 6MWT  was comprised of data points from participants who had lost ambulation at the time of the visit. There were significant differences in both SOL and VL FF between each of the four functional bins, with the highest FF values in the LOA group . Similar ability .With increasing VL FF, an increasing percentage of participants demonstrated loss of functional abilities . At low th-75th percentile = 0.38–0.54), while VL FF at the first visit in which they could not climb four stairs was 0.54 (25th-75th percentile = 0.43–0.64). Mean VL FF at the first visit following loss of ambulation was highest at 0.58 (25th-75th percentile = 0.48–0.69). VL T2 values followed the same trend, with T2 at the first visit following loss of ambulation occurring at the highest T2 value . These observations parallel the typical sequence of functional loss seen in the clinic. The status of the lower extremity musculature at the first nonambulatory visit is presented in 2 was never less than 60ms in nonambulatory participants An ROC curve of the relationship between ambulation status and VL FF showed an area under the curve of 0.91 (95% CI = 0.87–0.94), demonstrating the ability of VL FF to strongly discriminate between ambulatory and nonambulatory individuals.The mean VL FF at the first visit in which participants could not complete STS was 0.45  lower extremity qMR biomarkers, specifically FF and MRI T2, strongly correlate to ambulatory functional endpoints; 2) the strongest correlations are found with qMR measures in rapidly progressing muscles ; and 3) qMR biomarkers, particularly VL FF, are strongly associated with the loss of functional ability and can discriminate between ambulatory and non-ambulatory individuals.In DMD, the paucity of sensitive, noninvasive outcome measures for use in clinical trials has stimulated the development of qMR biomarkers of muscle pathology. This investigation represents the largest cohort study examining the relationship between qMR measures and clinically meaningful functional endpoints in DMD, a prerequisite for demonstrating the utility of MR biomarkers as surrogate outcomes in clinical trials. Using the multicenter Development of pharmacological therapies for DMD has advanced more rapidly than that of sensitive, noninvasive outcome measures to detect therapeutic efficacy in patients. Clinical outcome measures capture meaningful changes in functional ability but are not well-suited for functionally heterogeneous cohorts and may require impractically long trials to determine efficacy if used exclusively.,35–37 Fu2 and MRS FF and meaningful measures of ambulatory function as an important step towards establishing qMR as a surrogate endpoint. Demonstration of a strong correlation between qMR biomarkers and function, as shown in this large, multicenter investigation is necessary. However, these current promising results must be followed by an investigation of the ability of MR biomarkers to predict change in function under natural history and therapeutic conditions.At this time, qMR measures of lower extremity muscles have shown promise as biomarkers and potential surrogate outcomes in DMD. Quantitative MR is objective, sensitive, and noninvasive, and thus well-suited for clinical trials requiring longitudinal measures in a pediatric population. A surrogate endpoint is a biomarker where a change in the biomarker is “expected to reflect changes in a clinically meaningful endpoint.” This stu2 and MRS FF were measured in the VL, and correlations with function were similar for both biomarkers. MRI T2 is heavily influenced by muscle fatty infiltration, particularly in advanced disease, and closely correlates with FF over the course of disease progression, which is consistent with the similar correlations.[2 also showed a strong correlation to ambulatory function.[2 from the GRA and TP muscles, which are relatively spared, showed the weakest correlation to ambulatory functional endpoints.[In our primarily ambulatory cohort, qMR biomarkers from the most quickly progressing muscles, the VL and the BFLH, demonstrated the strongest correlations with all functional endpoints. Both MRI Telations. In agreefunction. MRI T2 fndpoints.2 of upper leg and pelvic girdle muscles and timed supine to stand and the 10m walk/run.[Prior studies in smaller cohorts have likewise found high degrees of correlation between qMR measures from quickly progressing proximal muscles and functional outcomes.–26,28,38walk/run.,25 A morThe relationship between qMR biomarkers and functional ability was strong (VL |ρ| = 0.68–0.78), but as anticipated, the correlation was not perfect for several reasons. First, individuals with DMD use remarkable compensatory mechanisms to maintain the ability to walk and perform functional tests, reducing the direct dependence of functional performance on muscle quality in a single muscle. Second, et al. found that boys who lost the ability to complete STS had a gluteus maximus FF >75%, and Fischmann et al. reported that loss of ambulation was associated with a mean FF of >50% for the quadriceps, hamstrings, and adductors combined.[ImagingDMD cohort, there is strong evidence that loss of ambulatory skills is closely related to the degree of proximal lower extremity muscle fat infiltration.Sentinel events such as loss of ambulation are important milestones in the progression of DMD and are used as endpoints in clinical trials and natural history studies. Loss of the ability to perform functional skills was strongly associated with fatty infiltration of the proximal lower extremity musculature, particularly the VL muscle. Apart from one outlier, in our cohort, no nonambulatory participants had a VL FF<0.40, indicating that this might be an approximate lower threshold of muscle pathology associated with loss of ambulation. Using chemical shift-based imaging techniques, previous studies found similar relationships between proximal muscle FF and loss of functional ability. Gaeta combined.,25 TakenThe robust relationship between qMR biomarkers and ambulatory function provides further evidence that qMR biomarkers, when implemented carefully, satisfy requirements for surrogate outcome status and should receive serious consideration for inclusion in clinical trials. These biomarkers are reproducible across multiple centers, highly sSelection of the most appropriate qMR biomarkers or muscles to be included in future clinical trials will depend on the specific cohort  and the goal of the therapeutic intervention. In the current study, qMR biomarkers of the VL and BFLH muscles correlated most strongly with both measures of ambulatory function and loss of ambulation. In our experience, qMR biomarkers from the VL offer additional advantages including the muscle’s clear functional role as a major leg extensor, its sensitivity to change over time, and its large size, which allows for excellent sampling of the muscle by MR spectroscopy or by manual segmentation. Thus, we1H MR spectroscopy rather than the popular Dixon imaging technique to quantify muscle FF. While each technique has strengths and limitations, MR spectroscopy, the gold standard for muscle fat quantification, is highly sensitive to disease progression and less susceptible to noise bias at low FFs. Finally, future investigations should explore the concept of composite qMR measures, which may be superior to individual muscle measures, but alternately may increase measure variability, decrease sensitivity, or obscure the relationship between measure change and clinical benefit.[A limitation of this study was that the analysis of loss of functional ability was somewhat restricted by inclusion criteria  and the small number of individuals who lost the ability to ambulate (n = 35) or climb stairs (n = 48) in this cohort. Additionally, although not a limitation, we elected to implement  benefit.Clinical trial progress in DMD has been impeded by a lack of sensitive, noninvasive, and objective outcomes and biomarkers suited for longitudinal studies in a pediatric population. Quantitative MR measures have emerged as valuable biomarkers to fill this void. One gap in the establishment of MR biomarkers has been a robust demonstration of the correlation with clinically meaningful measures of function and sentinel events. The results of this study, building upon the promising results from other groups with smaller cohorts, convincingly support the link between function and qMR biomarkers. Studies in other neuromuscular diseases have also demonstrated responsiveness of MR measures, highlighting the applicability of qMR biomarkers not only to DMD but potentially to a wider range of progressive neuromuscular disorders.–42


Visual loss is a devastating perioperative complication that can result from elevated intraocular pressure (IOP). The Trendelenburg position during surgery increases IOP. The purpose of this study was to quantify IOP changes in patients undergoing laparoscopic hysterectomy, at different time points and body positions throughout the procedure, and to compare fluctuations of IOP during the perioperative period according to two fluid management protocols. 2, and ocular perfusion pressure were assessed prior, during, and postsurgery, at 8 time points altogether.  Thirty women scheduled to undergo elective gynecologic laparoscopic pelvic surgery were randomly allocated to receive a liberal or restrictive fluid management protocol. IOP, mean arterial pressure, heart rate, exhaled tidal volume, end-tidal CO Mean changes in IOP were similar for the two protocols; the peak IOP was at the steep (peak) Trendelenburg position. For each protocol, IOP correlated positively with mean arterial pressure, and mean blood pressure correlated with ocular perfusion pressure.  IOP was elevated during laparoscopic pelvic surgery and particularly at the steep Trendelenburg position. No differences were found in any of the parameters examined according to a liberal or restrictive fluid management protocol. Visual loss is a devastating perioperative complication with an estimated incidence of 0.01–1%, depending on the type of surgery . Among t003-12-ZIV at the Israeli Ministry of Health.Laparoscopic surgery is associated with several physiological changes that tend to increase IOP . As for The study comprised 30 consecutive women who were scheduled for elective gynecologic laparoscopic pelvic surgery between January 1, 2015, and December 31, 2015, and who met study inclusion criteria. The exclusion criteria were age older than 70 years or less than 18 years, body weight > 150% of the ideal body weight, acute or chronic eye disease, use of any medication known to alter IOP, patients not capable or willing to sign informed consent. The study was approved by Helsinki Committee of Ziv Medical Center, and written informed consent was obtained from all patients prior to surgery.2 at 35–40 mmHg throughout the procedure. Pneumoperitoneum was created by intraperitoneal insufflation of CO2, with the patient in the supine position. Throughout the surgery, intraperitoneal pressure was maintained automatically at 14 mm Hg by a CO2 insufflator.Participants were alternately allocated to two equal groups (15 patients each), to receive either a liberal or restrictive fluid management protocol , based o2, entropy values, IOP and OPP, were recorded at the following time points: T1—before the induction of anesthesia; T2—after the induction of anesthesia, in a supine and horizontal position, mechanically ventilated, before pneumoperitoneum; T3—after the pneumoperitoneum was established; T4—while the pneumoperitoneum was established, with a 15°–20° head-down tilt; T5—while the pneumoperitoneum was established, steep (peak) Trendelenburg position; T6—after the pneumoperitoneum was evacuated in the horizontal position; T7—in the recovery room, 30 degrees head up, 30 min after tracheal extubation; and T8—on the first postoperative day. Since blood pressure affects IOP, we examined the relationship between MAP and IOP at various concentrations of fluid intake in both study groups.IOP was measured using a Tono-pen® XL by a trained ophthalmologist who was unaware of the perioperative fluid administration regimen. Measurements were repeated if the variability between sequential measurements exceeded 5%. Two sets of measurements for each eye were collected . All measurements were performed by the same team of ophthalmologists. The depth of anesthesia was continuously evaluated with an entropy monitor. MAP, heart rate (HR), exhaled tidal volume, ET CO2 with the patient in the supine position. Throughout the surgery, intraperitoneal pressure was maintained automatically at 14 mm Hg by a CO2 insufflator.After each change in position and intraperitoneal pressure, a 5-minute period was allowed for stabilization before measurements were performed. Pneumoperitoneum was created by intraperitoneal insufflation of COt-test for the independent groups was used to examine the difference of IOP between the two treatments . Pearson's correlation was used to calculate correlations between the continuous variables and chi-square correlation between categorical variables. Values at p < 0.05 were considered statistically significant. The study was approved by the local bioethical committee of Ziv Medical Center, Israel.The p < 0.0001; data for all 30 patients). Subsequently, a far greater increase in IOP was observed during and immediately following Trendelenburg positioning . The peak IOP for both protocols was when pneumoperitoneum was established and the position was the steep (peak) Trendelenburg position (T5). On the first postoperative day (T8), the mean IOP for both groups was approximately equal to the mean preanesthetic IOP (T1). For both fluid management groups, the relationship between IOP and MAP did not change at different fluid intakes. Considering the data of all 30 participants, IOP correlated positively with MAP  similar IOP measurements between patients who were treated with different preoperative fluid management protocols; (2) reduction in IOP following the induction of anesthesia in a supine and horizontal position and while patients were mechanically ventilated; (3) significant elevation of IOP during pneumoperitoneum and specifically in the steep Trendelenburg position; and 4) normal levels of IOP at about 12 hours postsurgery, similar to levels measured prior to the operation. Elevation of IOP may be problematic in patients who undergo gynecologic laparoscopic pelvic surgery and who also have chronic simple glaucoma. For patients with progressive damage to the optic disc, elevated IOP may exacerbate the injury to the retinal nerve fiber layer (RNFL) and further impair the visual field. In such patients, we suggest that a thorough ophthalmic examination, including a visual field test, the measurement of RNFL thickness and IOP, should be done prior to the gynecologic laparoscopic pelvic surgery. In extreme cases, gynecologists should consider another surgical approach, since, as shown in our study, the elevation of IOP in these surgeries is significant and the relatively long operating time raises the risk of damage to the RNFL. For measuring IOP, we used the Tono-pen due to its speed, ability to make measurements on multiple patients, ease of use including disposable latex tip covers, accuracy in a variety of positions,  reliabil normal lPneumoperitoneum, and specifically the steep Trendelenburg position, during gynecologic laparoscopic pelvic surgery may induce a significant elevation of IOP. This elevation was shown not to differ according to the protocol for perioperative fluid management. Surgeons who conduct such operations should consider this risk, especially in patients who already have glaucoma. Further studies are required to establish our findings.


Four groups received different treatments for the study: SCI control, MP, MP and EA, and Sham. The growth of nerve fibers was examined by counting fluorescein positive nerve fibers. The motor functional recovery was evaluated by Basso, Beattie, Bresnahan (BBB) score, and electrophysiology analysis. We found that, compared to MP groups, there were more well-oriented and paralleled fluorescein positive nerve fibers in MP and EA group. Both latencies and amplitudes of the Motor Evoked Potential (MEP) in the combination therapy of MP and EA were higher than MP group. Additionally, recovered hindlimb movements were sustained in most rats in the MP and EA group. Our study indicated that combination therapies could become a powerful treatment for SCI in rats.The present study aimed to evaluate the role of the combination treatment of methylprednisolone (MP) and electroacupuncture (EA) in regeneration of nerve fibers and functional recovery in rats with spinal cord injury (SCI). Female Wistar rats were used for an SCI model by using a weight-drop hammer at levels T A spinal cord injury (SCI) is damage or trauma to the spinal cord. Patients with SCI usually have temporary or permanent neurologic deficits and disability, including motor deficit, sensory deficit, breathing difficulty, and bowel and/or bladder dysfunction. SCI can be caused by accident, diseases, or degeneration. It is estimated that the incidence of SCI around the world is between 250,000 and 500,000 people every year .Steroids have been used in the management of acute SCI for decades due to anti-inflammatory effects and inhibition of lipid peroxidation . EspeciaAcupuncture is an ancient Chinese therapy by inserting the needles at certain points of the meridians to cure disease and relieve pain . ElectroIn the present study, we examined the role of combination treatment of MP and EA in axon growth and regeneration and hindlimb movement function recovery in rats with SCI.−1 immediately after SCI, repeated once 4 h after surgery, and then injected twice per day with 3 days; (3) MP and EA group: both MP and Hua Tuojiaji , Ming Men  and Da Zhui  acupoints were used in treatment 4 h after SCI; and (4) Sham group: vertebral plate was opened to expose spinal marrow without SCI. The acupuncture needles were 25 mm long and 0.35 mm in diameter. The 6805-II electroacupuncture therapeutic apparatus made in Shanghai is provided with a positive electrode and a negative electrode. EA parameters of 1-2 Hz at 0.3–1.0 mA were used in the present study. EA treatment was given once every day for 6 days, 15 minutes each time. After a 2-day interval, the second course started, with three courses in total. All surgical procedures were performed under general anesthesia with 3% pentobarbital sodium.Adult female Wistar rats (200–250 g) were purchased from the Experimental Animal Center of Jilin University. Animals were housed in a standard cage with the temperature 22 ± 1°C and humidity of 50%–60%. Animal experiments related to the study were approved by the Local Ethics Committee for Animal Research at Jilin University and performed in accordance with international standards for animal welfare. Rats were randomly divided into four experimental groups, which each contained 18 rats; specifically (1) SCI control group: no treatment after the SCI surgery; (2) MP group: intravenous injection MP 30 mg·kg10 (the 10th thoracic vertebra) level to expose the spinal segment and then a hammer (20 g) was dropped from a height of 30 mm onto the exposed dura mater. After the induced SCI, all rats received extensive care, including penicillin  and gentamicin (2000 U/per rat), for 7 days and thick, soft bedding in individual cage. Manual emptying of the bladders was performed three times daily. All procedures were approved and in accordance with the Institutional Animal Care and Use Committee guidelines at Jilin University.Adult female Wistar rats were anaesthetized with 3% pentobarbital sodium. A laminectomy was carried out at the TFunctional recovery was assessed by observers that were blind to groups of the experiment and graded each animal according to Basso, Beattie, Bresnahan (BBB) open field locomotion test . The BBBThirty days after surgery, six rats from each group were used to study motor evoked potentials. Following anesthesia with 3% pentobarbital sodium, a midline incision was made on the rat's head skin, and the cranium was exposed. One hole was drilled for the skull by using a standard dental drill. The sciatic nerve was exposed to the left leg. The stimulating electrode was placed beneath the scalp, recording electrode was placed on the sciatic nerve, and reference electrode was placed below hard palate. The MEP was induced and registered for evoked potential instrument of Powerlab and biofunction experiment system of BL-410  by appropriate stimulation parameters.Thirty days after surgery, six rats from each group were anesthetized with 3% pentobarbital sodium. At the second spinal segment of SCI area, fluorescein (FR)  was slowly injected using a Hamilton microinjector  at depths of 2.5 mm, 1.5 mm, and 0.5 mm away from the spinal dura mater, respectively, on both sides with the spinal cord. Four days after injection, the spinal tissue was removed, placed at 4°C in 4% paraformaldehyde overnight, and then replaced with 5%, 15%, and 30% cryoprotective sucrose for 90 min, respectively. Specimens were then quickly embedded in frozen OCT compound and stored at −80°C. Sections were prepared for a cryostat , cover-slipped with glycogelatin to preserve fluorescence, and observed under fluorescence microscopes.P < 0.01.Statistical analyses of electrophysiology MEP results were performed by single factor analysis of variance (ANOVA), and least significant difference (LSD) was used for intergroup comparison. Statistical analyses of functional recovery BBB score results were performed by the ANOVA of repeated measurement design based on the original data by using the SPSS program (version 13.0) for Windows . Differences are considered statistically significant if To evaluate the growth of nerve fibers after treatment for SCI rats, the FR-positive nerve fibers were counted in six rats for each group. As shown in To further examine the function of the severed spinal cord after treatment, the MEP was measured. As shown in To evaluate the functional recovery, the BBB score was determined by voluntary hindlimb movement towards each group. As shown in Recent studies have found that adult mammalian spinal cord injury leads to a series of neurological deficit symptoms , 12 and In our study, FR anterograde tagging indicated that many FR-positive nerve fibers were distributed among SCI area and extended to the distal side. Additionally, the nerve fibers were well-oriented and paralleled in the combination therapy of MP and EA. Furthermore, the latencies and amplitudes of the MEP in the combination therapy of MP and EA were higher than those in all other groups. In addition, recovered hindlimb movements were sustained in most rats in MP and EA group. The combination therapy of MP and EA might function via the following mechanism: (1) MP provides multifarious neuroprotective effects, including improving microcirculation, inhibiting lipid oxidation, reducing calcium influxes in cells, and maintaining nervous system excitability; (2) the EA treatment decreases the production of free radicals, regulates neuropeptide secretion, and improves the blood circulation of SCI.From the clinical and anatomical point of view, it is feasible to effectively restore the neural pathway in spinal cord injury by combining Chinese and western medicine , 20. EleIn summary, we have presented data that indicate that the comprehensive therapy of EA in rats with SCI can effectively enhance the growth of nerve fibers and improve the hindlimb motor function recovery, suggesting that combination therapies could become a powerful treatment for SCI.


On an appropriate scale, geographically weighted regression (GWR) models were employed to interpret the influences of socioeconomic and environmental factors on this epidemic across the GF area. DF transmissions in Guangzhou and Foshan cities presented synchronous temporal changes and spatial expansions during the main epidemic months. Across the GF area, this epidemic was obviously spatially featured at various grid levels, especially on the 2 × 2 km2 scale. Its spatial variations were relatively sufficiently explained by population size, road density, and economic status integrated in the GWR model with the lowest Akaike Information Criterion (AICc = 5227.97) and highest adjusted R square (0.732) values. These results indicated that these three socioeconomic factors acted as geographical determinants of spatial variability of the 2014 DF epidemic across the joint GF area, although some other potential factors should be added to improve the explaining the spatial variations in the central zones. This work improves our understanding of the effects of socioeconomic conditions on the spatial variations in this epidemic and helps local hygienic authorities to make targeted joint interventions for preventing and controlling this epidemic across the GF area. Dengue fever (DF) is a common and rapidly spreading vector-borne viral disease in tropical and subtropical regions. In recent years, this imported disease has posed an increasing threat to public health in China, especially in many southern cities. Although the severity of DF outbreaks in these cities is generally associated with known risk factors at various administrative levels, spatial heterogeneities of these associations remain little understood on a finer scale. In this study, the neighboring Guangzhou and Foshan (GF) cities were considered as a joint area for characterizing the spatial variations in the 2014 DF epidemic at various grid levels from 1 × 1 km Aedes aegypti and Aedes albopicuts mosquitoes. Dengue is an endemic infectious disease in most of the tropical and subtropical regions, especially in Southeast Asia, the Western Pacific, Latin America, and Eastern Mediterranean regions [Dengue is a vector-borne tropical disease caused by the four dengue virus serotypes DENV 1–4) that is mainly transmitted by –4 that i regions ,3. There was no dengue fever (DF) case documented in China from 1949 to 1977 until an outbreak emerged in Guangdong Province in 1978. DF is still believed to be an imported infection in China, although the threat of DF outbreaks has become more and more serious over the past 15 years, especially in areas of Southern China including Guangdong, Zhejiang, Yunan, Fujian, and Guangxi Provinces ,7. In thAedes albopictus mosquitoes (dominant species in the Pearl River Delta (PRD)) due to the suitable settings [Once the DF outbreaks occur in the non-endemic regions, local DF transmission likely depends on the interactions between host, viruses, mosquitoes, and environmental factors ,5. Givensettings ,17,18,19settings , revealiGuangzhou and Foshan (GF) to be One” project.As one of the most economically developed regions, the Pearl River Delta (PRD) is frequently confronted with a serious situation of DF prevention and control because it has the most cases—accounting for more than 90%—in China ,22. DF ePrevious studies that focused on the causes and influencing factors of the DF epidemic have improved our understanding of the causes of the increasingly serious infection situation in the south of China ,10,22. HGuangzhou and Foshan to be One” project. The area, which has a population of about 21 million and had the economic level of gross domestic product (GDP) per capita of about 125,000 yuan in 2015, is featured by warm, humid, and rainy meteorological conditions of the maritime monsoon climate.Guangzhou City  and Foshan City  have become more closely bound as a core zone and arelabeled the joint GF area in the central region of Guangdong Province  due to t2, 2 × 2 km2, 3 × 3 km2, 4 × 4 km2, 5 × 5 km2, and 6 × 6 km2 were created with the Fishnet Tool in ArcGIS 10.0 .Compared with the county, town, village, or district scale used as basic geographic units in previous spatial epidemiology studies, the instability of calculating or processing research objects is subject to disturbances caused by the irregularity and nonconformity of constantly changing administrative divisions ,5,22,25.http://www.gpsspg.com/xGeocoding/), all of the local cases without recent travel experience were spatially positioned according to their addresses  at spatial grid i, which is specific for every spatial grid; Given the spatiotemporal heterogeneity of dengue fever incidence rates, the related factors may affect the epidemic in different ways and to various degrees, which is appropriate to analyze using a geographically weighted regression (GWR) model. As an extension of the traditional multiple linear regression , a GWR model embeds the attributes’ spatial location into the regression parameter, yielding a local regression together with local estimates of regression coefficients . The locIn this study, Pearson correlation analysis was chosen to explore the relationships between DF incidences and all of the potential variables  at the significance level of 0.05 and 0.01, by which some appropriate potential variables could be accordingly considered into the GWR and/or OLS models.All of the above spatial analysis and modeling were completed in ArcGIS 10.0 software . Typical correlation analysis was achieved using SPSS 14.0 .In total, there were 40,450 locally infected patients confirmed by laboratory diagnosis in Guangzhou City and Foshan City. Their local DF epidemic presented similar temporal changes C. The ovAt the spatial levels from 1 km × 1 km to 6 km × 6 km, the natural logarithm values of SEB-smoothed incidence rates presented obvious spatial clustering across the GF area, especially on the 2 km × 2 km scale, due to relatively high Morans’ I and larger z-score values . On thisIn comparison, spatial differentiations of socioeconomic variables A–D were Based on the selected explanatory variables  at the 2 km × 2 km level, the GWR models accounted for larger proportion of the spatial variations in the 2014 DF incidence rates than that of OLS models in terms of the values of higher adjusted R square and lower AICc . The interpreting abilities of GWR models tended to be different from each other due to various combinations of these selected variables. When discarding NDVI, the GWR models (B–F) possessed better capacity (0.623 < Adjusted R square < 0.732) of simulating the spatial variations. While GDP, population size, or road density was further deleted respectively, the performances of the GWR models (D–F) were obviously decreased. In comparison, the GWR model C displayed the best performance (Adjusted R square = 0.732) of interpreting the spatial variations while only LUL was further discarded. In addition to the highest adjusted R square and the lowest AICc values, the range of local R square values derived from the GWR model C was the widest as shown in The 2014 DF incidence rates were spatially interpreted in the districts such as Nanhai and Chancheng in Foshan City and Baiyun, Liwan, Tianhe, and Haizhu in Guangzhou City due to the clustering grids with relatively higher local R square than 0.4 A. The grIn addition, the strength of the local correlation between population size, road density, economic status, and this epidemic was spatially differentiated across the GF area . PopulatIn this study, we analyzed the influences of socioeconomic and environmental factors on the spatial variations on the grid scale in the 2014 DF epidemic in the joint GF (both Guangzhou City and Foshan City) for the first time in China. GWR models were employed to effectively explore the determinants of spatial variability of this epidemic. Several notable findings were achieved and could provide meaningful clues for public health authorities implementing effective interventions on this infection. Guangzhou and Foshan to be One” project. In our study, the monthly DF epidemics in Guangzhou City and Foshan City presented similar features of temporal changes and spatial expansion. One explanation for this phenomenon is that neighboring Guangzhou City and Foshan City possessed similar meteorological conditions, approximate population density, large commuting population (working in one city and residing in the other one) by increasingly maturing integrative traffic system, common floricultural habits, and so on. These common crucial factors determined that these two cities were confronted with a DF outbreak risk at similar levels and their epidemics tended to be affected by each other ,23,24. AThe outbreak size and peaks of the 2014 DF epidemic in Guangzhou City were mainly determined by the increasing imported DF cases and much heavier rainfall in May and August . After tAedes albopictus mosquitoes due to crowded population [Aedes albopictus mosquitoes’ breeding, growth, and perching, especially after a moderate rainfall [Besides the most serious DF epidemic being across the GF area, the central zones were also obviously featured by higher road density, moderate economic status, and a more crowded population . Accordipulation ,13,15,33pulation . Togetherainfall ,18,19,34rainfall ,35,36. Arainfall ,38,39,40A few limitations of this study warrant mentioning. First, the suitability of the 2 km × 2 km scale for characterizing the DF epidemic during all of the other years should be further assessed, although it was the most appropriate for the most serious 2014 DF epidemic across the GF area. Second, remote sensing images should be adequately used to retrieve more information, such as more detailed and real ground temperature and humidity values and more widely distributed urban villages, by which the zones with relatively higher (>2) or lower (<−2) StdResid B and higIn summary, our study proved that spatially differentiated road density, population size, and economic level were the main determinants of spatial variability of DF epidemic on the grid scale in the joint GF area (Guangzhou and Foshan). This work improves our understanding of the effects of socioeconomic conditions on the spatial variations in this epidemic and helps local hygienic and environmental authorities to make targeted joint interventions for preventing and controlling this epidemic across the GF area.


Taraxacum officinale plants. In addition, thickness of a seed and Endosperm to Seed Coat Proportion (ESCP) in a second generation (F2) was measured to evaluate the heritability of this seed trait. On the other hand, we characterized the genetic variability of the sampled individuals with amplified fragment length polymorphism (AFLP) markers, analyzing its spatial distribution and population structure. Overall, thickness of seed coat  decreases with latitude, indicating that individuals of T. officinale from northern populations have a thicker seed coat than those from southern populations. Germination increased with greater addition of water and seeds from southern localities germinated significantly more than those from the north. Additionally, reciprocal transplants showed significant differences in survival percentage and biomass accumulation among individuals from different localities and moreover, the high correlation between maternal plants and their offspring can be suggesting a high grade of heritability of this trait. Although genetic differentiation was found when was considered all populations, there was no significant differentiation when only was compared the northernmost populations which inhabit in the driest climate conditions. Our results suggest that climatic conditions could affect both, the ESCP and the genetic variability in the invasive T. officinale, suggesting that this seed trait could be indicative of adaptive selection. Thus, colonization along broad geographical gradients in many cases may be the result –in part- for the presence of functional traits as shown in invasive plant species with rapid adaptive capacity.It has been widely suggested that invasion success along broad environmental gradients may be partially due to phenotypic plasticity, but rapid evolution could also be a relevant factor for invasions. Seed and fruit traits can be relevant for plant invasiveness since they are related to dispersal, germination, and fitness. Some seed traits vary along environmental gradients and can be heritable, with the potential to evolve by means of natural selection. Utilizing cross-latitude and reciprocal-transplant experiments, we evaluated the adaptive value of seed thickness as assessed by survival and biomass accumulation in  Most of invasive species spread in their non-native environments occupying large geographical areas, resulting in plant populations that experience very different climatic conditions . Hence, Lythrum salicaria (purple loosestrife) exhibited distinct flowering time and flower production characteristics in its introduced range in comparison to its native range, suggesting rapid evolution in several reproductive traits. In addition, Lactuca serriola, noted the capacity of non-native populations to rapidly produce phenotypic and genetic adaptive variation along the invaded climate gradient. Furthermore, they proposed that this response could be related to its wide native geographic distribution and the consequent environmental variation.The early studies of It has been shown that selective pressures may drive contemporary evolution within exotic plant populations in different ways. In particular, abiotic gradients across the introduced range could impose divergent selection and promote genetically based differentiation among introduced populations see . A classSeed and fruit traits are critical for dispersal syndromes and mechanisms to cope with environmental stress. They are also sensitive to changes in biotic and abiotic conditions . For exaTaraxacum agg. (aggregate dandelion complex), the dispersal unit is the achene, a fruit which is formed by a single seed with a differentiated seed coat and endosperm, enclosed in a dry (not fleshy) and hard pericarp. In T. officinale, seed coat is fused with achene wall, and it is the achene that is dispersed, acting ecologically as a seed  does this variation have any adaptive relevance as assessed by greater germination, survival and biomass?, (iii) are these functional seed traits heritable?, and (iv) Are phenotypic variation and genetic diversity clinally distributed along the precipitation gradient? We assessed these questions by measuring the thickness of both endosperm and of coat, as well as the endosperm to seed coat proportion (ESCP) in individuals of T. officinale from 25 populations (distanced among them for 1–1.5 km) and clustered in five localities (with five populations each one) distributed along a latitudinal rainfall gradient in Chile. Additionally, we evaluated the germination percentage in seeds from these five localities exposed to different amounts of water. We also evaluated the possible evolutionary change in seed traits and its adaptive consequences through two approaches: first, we evaluated the percentage of seeds germination of populations from the northern and southern limits of the gradient  through a cross-latitude experiment. Second, we conducted a reciprocal transplant experiment to assess the survival of adults and biomass accumulation with the same set of individuals from two localities (La Serena and Coyhaique). On the other hand, we estimated the heritability of ESCP by analyzing the linear relationship between the expression of this trait in maternal plants and their progeny. Additionally, we assessed the genetic differentiation among populations along the latitudinal gradient and also explored the relationships between genetic differentiation and geographic, trait, and environmental distances. Finally, since T. officinale often reproduces through asexual seed production (apomixis), we also used molecular markers to quantify the proportion of clones within populations, as among populations genetic and seed traits differentiation could be strongly affected by increased clonality due to this reproductive system.In the present study we addressed the following questions: (i) does the mean thickness of endosperm and coat , and the average proportion between the endosperm and the seed coat (as considered above) vary between populations of Taraxacum officinale Weber ex. F.H. Wigg. (Asteraceae) were collected in 25 populations from five different locations in Chile: Caldera, La Serena, Valparaiso, Concepción and Coyhaique. This broad latitudinal gradient covers from ca. 27°S to ca. 46°S, including a pronounced rainfall gradient that harbors a mean annual precipitation increase from 41 to 1306 mm in the sampling sites . All populations were separated at least by 1 km and at elevations between 0 and 50 m to reduce altitudinal effects. A range of 5–10 achenes (seeds hereafter) per individual was collected from 20 to 30 sampled plants per population to form the initial seed pool. As T. officinale has apomictic reproduction (production of seeds without fertilization), samples were taken from widely separated plants to capture a representative sample of phenotypic variation and genetic of each studied population. First generation plants (F1) were generated from this initial seed pool and were grown in a greenhouse at Universidad de Concepción, Concepción under natural conditions of light and temperature (day conditions(08:00-19:59h) = 978 μmol m-2 s-1 ± 85 and 18°C ± 3, and night conditions (20:00-07:59h) = 122 μmol m-2 s-1 ± 49 and 5°C ± 2). These plants were put in 300-mL plastic pots filled with potting organic soil and irrigated every 2 days with 50 ml of water. After 5 months these plants produced the achenes that were used to obtain experimental plants (F2).Seeds of F2) in each locality  to measure the thickness of endosperm and coat, as well as the ESCP. Each seed was cut in half on the equatorial axis with a razor blade. Sectioned seeds were maintained with the section face up using modeling clay and photographed with a digital camera (Motic 3000 Cooled). Each picture was analyzed with specific software for analysis of digital images . The computer coupled with the digitalization software gave the area and thickness of endosperm and coat of each seed. In addition, the ESCP was calculated as thickness of endosperm (endosperm plus embryo) relative to thickness of coat , both in the equatorial section of seed. To assess the variation in the ESCP with latitude, a linear regression was conducted. In addition, differences in the thickness of in both endosperms and coat, and ESCP among localities were assessed with one-way ANOVA and Tukey’s HSD post hoc comparison test.We randomly selected five seeds from five different maternal plants (3 of density) as substratum in order to avoid loss of humidity . Five Petri dishes  were watered with 10, 25, 50, or 100 ml of distilled water on two occasions (n = 100 Petrie dishes). We selected these amounts of water because they represent typical conditions seeds might encounter in real conditions along the latitudinal rainfall gradient. All Petri dishes were watered once at the beginning of the experiment and placed in a growth chamber with 14/10 day/night photoperiod and 20 ± 1°C constant temperature. Dishes were covered with filter paper, and in order to maintain the differences in water availability for each watering condition, weight of each Petri dish was measured every 3 days throughout experiment. Germination was recorded daily until no new germinated seeds were observed for three consecutive days (day 30). The germination percentages among localities were compared with one-way ANOVA for each watering treatment after arcsine transformation and Tukey’s HSD post hoc comparison test.Germination assays were carried out in order to test whether the structural trait analyzed here (ESCP) affected germination under different watering treatments. For each locality, 20 Petri dishes (100 × 15 mm) with 40 seeds each were prepared using two layers of wet filter paper  were collected and bulked previous to buried at 1 cm of deep in plastic boxes (20 × 20 × 15 cm) arranged in the field. The cross-latitude experiment was conducted in both localities and with seeds from La Serena and Coyhaique. In each locality, we put 20 boxes with ten seeds each, of which half contained seeds from the La Serena, and the other half contained seed from the Coyhaique. In addition, we filled two plastic boxes with soil from each site without addition of seeds in order to assess the presence of T. officinale in the seed-bank. Each box was watered once with 10 ml in the locality of La Serena and with 100 ml in the locality of Coyhaique in order to mimic a typical rainfall of 2 days in each locality. Once per week, over 7 weeks, germination was recorded in each box. Germination percentage at 7 weeks of T. officinale individuals from both localities was compared by one-way ANOVA. Comparisons were conducted independently for each locality where individuals were transplanted.We conducted a cross-latitude experiment using seeds collected from plants from five populations in La Serena (29°54′S) and five in Coyhaique (45°61′S) to investigate possible evolutionary change in endosperm to coat seed proportion and its adaptive consequences. At each of these populations we collected seeds from forty maternal plants and maintained them in paper bags. Forty seeds from each population  of 250 (±12) μmol m-2s-1 and 16/8 h light/dark photoperiod. This temperature was chosen because this is an intermediate of annual mean temperature of both localities . Each group of ten individuals (population) was separated by 1 m between each point of transplant. The plants were watered once every day only for the first week in order to reduce the death of plants due to the transplants. Once per week, over 10 weeks, survival was recorded for each plant maintaining the recording separated by locality of origin. All surviving plants were harvested after 10 weeks and total plant biomass was obtained after the whole plants were oven-dried at 70°C for 72 h. Considering that neither survival percentage  nor biomass  differed between populations from the same locality of origin, we merged the results by locality. Survival percentage and biomass at 10 weeks of T. officinale individuals from both localities were compared by one-way ANOVA (STATISTICA 7.0). Comparisons were conducted independently for each locality where individuals were transplanted.We conducted a reciprocal transplant experiment with plants originated of five populations from the two studied localities (La Serena and Coyhaique) to investigate possible evolutionary change in ESCP and its adaptive consequences. At each of these five populations in each locality, we collected seeds from 40 maternal plants, and germinated in a room with a photon flux density (PFD) of 470 (±135) μmol mcalities . Ten 1-msensuWe estimated the heritability by analyzing the relation between the ESCP of maternal plants and the same trait in their progeny  in order to clean of “maternal effects.” From this second generation, five maternal plants per population were obtained in order to produce the experimental progeny (F3). Seeds were germinated in Petri dishes and 2-week-old seedlings were planted in pots with a 1:1 sand:commercial soil mixture. All pots were watered every 3 days at field capacity. Plants were grown in a common environment in a greenhouse until flowering . Although T. officinale has been described as an apomictic species, it is also self-incompatible  and compared by a regression analysis , and their integrities verified by electrophoresis in a 1% agarose gel. The genetic diversity and population structure were estimated using Amplified Fragment Length Polymorphism (AFLP). The AFLP protocol was performed following the description of 2, 0.25 mM of each dNTP, 0.5 μM Eco + A primer, 0.5 μM MseI + C primer and 1U of AmpliTaq Gold® DNA polymerase. PCR amplification was carried out with a profile of 20 cycles of denaturation 30 s at 94°C, annealing 1 min at 56°C, and extension 1 min at 72°C. After PCR amplification, amplification products were diluted 1:10 with distilled water and stored at -10°C. Selective amplifications were performed using a 1 μL of diluted preselective amplification as a template in reactions containing 1x PCR buffer, 1.5 mM MgCl2, 0.25 mM of each dNTP, 0.5 μM Eco + ANN (fluorescent) primer, 0.5 μM Mse + CNNN (or Mse + CNNN) primer, and 1U of Platinum Taq DNA polymerase (Invitrogen Brazil). Selective amplifications started with a touchdown step of 2 min at 94°C, then 10 cycles of 30 s at 94°C, 30 s at 65°C (1°C decrease each cycle) and 1 min at 72°C. This was followed by 30 cycles of 30 s at 94°C, 30 s at 56°C and 1 min at 72°C, ending with a final elongation of 30 min at 72°C.Total DNA was extracted from dry foliar tissue of plants previously assessed in each locality according to cetyl-trimethyl-ammonium bromide (CTAB) method , followiHE), percentage of polymorphic loci  and Shannon’s index of diversity (I) were estimated using GENALEX . Both, FST and AMOVA analysis were performed in Arlequin 3.5  using the -package , and hiequin 3.5 , all othquin 3.5 .FST) and geographical distance (Euclidean), differences in mean annual rainfall and differences in seed coat to endosperm proportion. The level of correlation between pairs of distance matrices was estimated using Mantel test’s  is common in dandelions . Thus, iN – MLLs) / N. The analyses were run considering the following parameters: (i) a threshold of 6 loci , (ii) an infinite allele model, (iii) 1,000 permutations and (iv) randomizing of alleles over individuals within populations, and over individuals over all populations. Since most studies to date have reported threshold values between 2 and 4% . Contrarily, the thickness of endosperm (endosperm plus embryo) was not different  between seeds of individuals from all localities . On the other hand, seed coat thickness showed a significant variation with latitude, with T. officinale from northern populations having a thicker seed coat than those from southern populations .The ESCP showed a strong and significant positive relationship with mean annual precipitation . Seeds from southern localities showed significantly higher percentage of germination  than those from the northern ones . This trend was more pronounced in the treatment with a lower water addition .Germination percentage increased considerably in the treatments with greater addition of water  than those from La Serena when they were buried in La Serena . In contrast, seeds of T. officinale individuals from both localities when were buried in Coyhaique showed similar germination percentage .Overall, the germination experiment showed that germination percentage was higher in those seeds with slimmer seed coat and in those located in Coyhaique. Specifically, seeds produced by Figure 4). Specifically, T. officinale individuals from La Serena had significantly higher survival percentage  than those from Coyhaique . Interaction between site of transplant and origin of plants (S × O) was significant , since individuals of Coyhaique had lower survival than those from La Serena but only when they were transplanted in La Serena . In addition, the biomass accumulation in T. officinale individuals from both origins was significantly greater when were grew-up in Coyhaique . Interaction (S × O) was significant , since individuals of Coyhaique had higher biomass accumulation than those from La Serena but only when they grew-up in Coyhaique .On the other hand, the reciprocal transplant experiment showed that both survival and biomass were similar among populations within each origin but differed between La Serena and Coyhaique , suggesting that this trait is heritable and has the potential to evolve by natural selection .The expression of the ESCP showed a significant positive relationship between maternal plants and their progenies (eH) was 0.183 (±0.007), ranging from 0.129 (±0.014) in Valparaiso to 0.229 (±0.015) in Caldera. Similarly, the mean percentage of PL was 52.4%, ranging from 39.2% in Valparaiso to 71.3% in Caldera. None of these estimators were correlated with the environment, latitude or seed traits (Table 1).Overall, the levels of within-locality genetic diversity were moderate. The mean unbiased expected heterozigosity . In a mixed cluster the northern localities of Caldera and La Serena denote their close genetic relationship, but also a strong differentiation from the rest of individuals. In the other hand, individuals from the more southern localities of Valparaiso, Concepcion and Coyhaique, albeit each one appeared as isolated groups, they are all opposed to the northern localities . Consistently, genetic differentiation (pairwise FST) between Caldera and La Serena was not significantly different from zero, averaging 0.56 and ranging from 0.31 between Valparaiso and Coyhaique localities, to 0.82 between Valparaiso and La Serena . A four-localities structure, following the DAPC and FST results, was proposed for testing in the analysis of molecular variance (AMOVA): Valparaiso, Concepción and Coyhaique as individual groups, and Caldera and La Serena joined in the fourth one. This analysis revealed a strong locality structure  with the remaining ∼38% of the observed variation as within-locality variation.The Discriminant Analysis of Principal Components (DAPC) analysis revealed four clusters with a major disruption between north-south localities , there was no relationship between any of them and the matrix of pairwise genetic distances, as showed by the significance of the Mantel test coefficients (Table 1). Nevertheless, the Mantel correlation  suggest an interesting trend between the genetic and the phenotypic traits .Finally, despite high levels of correlation were found between the geographical, environmental and trait distance matrices among localities  Thus, the average clonal fraction (for the entire dataset) was 0.16, ranging from 0.11 in Caldera to 0.20 in Coyhaique . These values are similar to those found in the southern populations of Chile, where the annual rainfall is similar to the native range  according the climate conditions experienced in each locality in order to germinate and establish permanent populations.In seminal studies of biological invasions, evolutionary biologists postulated that genetic variation and adaptive evolution through natural selection are involved in the success of invading species . A growiT. officinale populations appeared to be highly related to experienced variation in rainfall. But moreover, as they also show evidence for genetic differentiation and heritability in those traits, the potential to adapt to local environmental conditions and thus evolve in their new habitats rapidly, is not rule out for this species. This could be observed in the two northern locations, Caldera (27°05′S) and La Serena (29°54′S), despite being 402 km apart, their similar extremely dry conditions seem to greatly influence the genetic composition of T. officinale individuals. Currently, similar genotypes are present in both localities (pair-wise FST = 0.002) such as to consider them as belonging to the same population , favoring individuals with thicker and thinner seed coat in driest and wetter sites, respectively. Second, T. officinale was introduced repeatedly from multiple origins, and only those genotypes that were pre-adapted to the new environment could maintain themselves over time. For example, those genotypes in the northern populations of Chile may have received propagules from a dry locality in its native range, or even from other dry sites of the non-native range . However, the high genetic similarity between the populations of these two localities suggests that they were originated from the same colonization event. Future studies should address the hypothesis of multiple introduction events of T. officinale, by mean of phylogeographic approaches, to understand the evolutionary processes of differentiation in its introduced range  population showed thicker coated seeds than those from wetter southern populations, and this seed trait was correlated with higher fitness when were sown in site with abiotic conditions similar to those found in their origin as showed by survival experiments. Thus, seeds with thicker coat will be successful in sites with low precipitations in order to avoid germination when abiotic conditions are not suitable. Precipitation here are scarce and seeds will need to germinate only when a certain amount of water is available, avoiding high seedling mortality. On the other side, populations growing in the southern sites produced seeds with a slim seed coat since with water availability for a good germination and early seedling growth is not limiting. The adaptive value of seed coat thickness was highlighted when the germination percentage of seeds from rainy population was significantly higher than the driest population, but the mortality was more pronounced in the rainy population. On the other hand, although both populations showed high germination percentage when sown in moist environment, those from the rainy sites showed significantly higher growth than dryer sites. Thus, ours results suggest that the clinal variation in the seed coat thickness of T. officinale populations has an adaptive value, positive impacting colonization and invasion of broad environmental gradients.Considering the apomictic  reproductive mode of T. officinale has been previously addressed (F2) and to assess the level of heritability we used a third generation (F3). In both cases, all “maternal plants” were growth under similar conditions but its seeds maintained the differences in the morphologic characteristics, suggesting the at least the seed-coat thickness is a not plastic trait.Alternatively, broadly distributed plants species must deal with a wide range of environmental conditions and respond to challenges imposed by environmental conditions by means of phenotypic plasticity . Ecologiddressed , 2018. NT. officinale seems to have a successful strategy that results in a great invasive potential. It seems that this invasive plant could likely evolve into specialized ecotypes reaching zones with contrasting climatic conditions. We are still far from comprehending the full process of invasion and the associated putative evolutionary process, nonetheless assessing more species or performing integrative analysis  we might find promising approaches to better understand the role of evolutionary processes in invasion.Since rainfall regimes are changing worldwide due to global change processes , it is eMM-M, CT-D, IA-R, and CA designed the experiments. MM-M, RH, AL, and TF performed the experiments. MM-M, CT-D, IA-R, RH, and TF analyzed the data. MM-M wrote the paper along with CT-D, IA-R, and CA. All authors reviewed the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Natural sources of mercury, historical gold mining, and contemporary artisanal and small-scale gold mining (ASGM) activities have led to mercury contamination in Suriname. Our primary objective was to evaluate mercury levels in hair of women and children from interior villages in Suriname where mercury levels in fish are elevated. We also estimated blood levels of mercury using an established mathematical conversion to facilitate comparison with other biomonitoring programs in the United States. Estimated levels of mercury in the blood of participants from Suriname were significantly higher than those in women from a heavy marine fish-consuming population in southeast Louisiana and estimates of the US national average. This includes women from Surinamese villages well upstream of ASGM activities. Since residents in these areas rely heavily on local fish, this is likely the source of their exposure to mercury. The levels in hair are similar to those seen in women from longitudinal studies finding neurological impairments in children exposed pre- and postnatally. Additional biomonitoring and neurodevelopmental assessments are warranted in these areas, as well as other areas of the Suriname. Mercury levels in hair (Suriname) and blood (southeast LA USA) were determined using cold vapor atomic absorption spectroscopy (CVAAS). Mercury is a ubiquitous environmental element that can be found in a variety of inorganic and organic chemical forms ,2. MercuExposure to mercury in any general, non-occupational population occurs mainly through the diet, and in many cases, through the consumption of fish ,23,24,25Sources of mercury in the environment include both natural and anthropogenic. Natural off-gassing of mercury from the Earth’s crust is a primary source in the atmosphere . AnthropThe United States Environmental Protection Agency (USEPA) has set a daily intake rate or reference dose (RfD) for methylmercury by way of oral ingestion at 0.1 µg/kg body weight . The WorHeavy fish consumers, especially women who may become pregnant, or pregnant women along with their developing children, are at most risk from exposure to methylmercury. Women and children in coastal areas, where fish and seafood are major sources of food, as well as inland areas, where bodies of water provide an abundant supply of fish for personal consumption and commercial purposes, are expected to experience the highest exposures to methylmercury from fish consumption ,24,29,42There are concerns regarding high exposures to mercury in the general population in the South American country of Suriname. A pilot study in 2005 found that 14 of 39 36%) women evaluated had mercury levels in hair that were elevated in comparison with a US reference population . However% women eThe communities of five villages were investigated regarding mercury levels in hair . Of thesA description of the research participants from Louisiana (LA) can be found in Zilversmit et al. . Data fr2SO4) and nitric acid (HNO3) for 12 h at room temperature, and then heated to 75 °C for 1 h; 100 mL of ultra-pure deionized water was added to the digested solution with 15 mL of 5% potassium permanganate (KMnO4). Samples were then placed in a 95 °C water bath for 2 h and then allowed to cool. After cooling, 6 mL sodium chloride-hydroxylamine and 5 mL tin(II) chloride (SnCl2) was added to the hair samples. Mercury measurements were performed using a Bacharach mercury analyzer following cold vapor atomic absorption techniques [Approximately 1 g hair samples were collected to evaluate Hg levels as a biomarker of chronic exposure. Each sample was labeled and placed into sample bags for subsequent mercury analysis and transported to the NZCS/CMO laboratory for Hg analysis. Hair samples were rinsed with ethanol. Samples (0.5 g dry weight) were digested in 250 mL containers using 2.5 mL of both ultra-pure sulfuric acid  of methylmercury of 1.6 µg/kg/week (2.3 × 10−1 µg/kg/day). HQs were generated using individual body weights where possible, and a standard, conservative value of 60 kg when individual body weights were not available. The HQ calculation was simply the estimated daily dose divided by either the USEPA’s RfD or the WHO’s PTWI. Hazards were considered excessive when the HQ ≥ 1.Microsoft Excel for Windows (2013) was used for estimating Hg daily doses for calculating hazard quotients . Hazard Fish consumption and intake rates were assessed using mercury levels in fish from previously published reports to determine the plausibility of consumption of locally harvested fish being the primary source of exposure ,37,38. Tp < 0.05.Prism was used for all statistical analyses, as well as for generating graphs and summary statistics . Data were checked for normality prior to statistical testing, and if deemed non-normal, non-parametric methods were used for testing. Either parametric ANOVA or non-parametric Kruskal-Wallis tests were used to determine if there were statistically significant differences in hair or blood mercury levels among the sites, including subvillages within the Brownsweg village, in Suriname, and among Surinamese and US sites and data. Post hoc mean comparisons were corrected using Dunn’s test. The Wilcoxon signed rank test was used to analyze medians from Suriname villages and LA using theoretical medians, including the USEPA action level for blood Hg of 5.8 µg/L, and the NHANES level of 0.93 µg/L. Correlation testing (Spearman’s r) was performed to examine the relationship between repeat samples taken in April 2009 and August 2009 from the same participants in Brownsweg. The Wilcoxon matched pairs test was used to determine if there were significant differences between repeat samples from these participants as a means to examine any seasonal or temporal variability. Correlation testing (Spearman’s r) was performed to examine the relationship between hair Hg levels and age. Results from statistical testing were considered significant at Descriptive statistics for research participants in Suriname are presented in Hair and blood Hg data did not pass tests for normality, so all subsequent analyses used non-parametric methods. p < 0.0001) and that Brownsweg had significantly lower levels of hair Hg than the other four villages (p < 0.05). Kruskal-Wallis (K-W) testing followed by a means comparison test indicated there were significant differences in hair Hg levels among the Surinamese villages  than participants from southeast Louisiana (p < 0.0001). A Wilcoxon signed rank test using the USEPA action level of 5.8 µg Hg/L of blood as a theoretical median indicated that participants in the Surinamese villages had median levels that were significantly higher than this action level (p < 0.0005) and that the participants in southeast Louisiana had median levels that were significantly lower than this action level (p < 0.0001). Blood Hg levels did not differ among non-pregnant and pregnant women from the LA cohort (p < 0.16). A Wilcoxon signed rank test using the NHANES level of 0.93 µg Hg/L of blood as a theoretical median indicated that participants from LA had significantly higher median levels of blood Hg than the US national average (p < 0.0001).Kruskal-Wallis testing followed by a means comparison test indicated that participants in all Surinamese villages had significantly higher levels of blood Hg , and the Wilcoxon matched pairs signed rank test indicated that levels from these two time points did not significantly differ .Repeat sampling of participants in Brownsweg in April 2009 and August 2009 resulted in 125 matched pairs. Correlation analysis indicated that hair Hg levels were highly correlated .Kruskal-Wallis testing, followed by a means comparison test, indicated that only the subvillages of Makambi and Biri Udu Mata among all subvillages in Brownsweg had hair Hg levels that significantly differed from one another . Correlation analysis of age and hair Hg levels with 230 matched pairs indicated no significant association between these two variables  or the WHO PTWI (1.6 µg/kg/week). HQs ≥ 1 for non-cancer health risks are usually used in the US as a trigger for action or intervention. Data from LA participants are included for comparison.Consumption of locally harvested fish is a probable source of exposure to Hg in the participants in these Surinamese villages ,36,37,38Mercury levels are highest in participants from Poesoegroenoe. This village is upstream of the active gold mining. Mercury levels in predatory fish here are elevated, but on average, they are below the EPA standard for human consumption . HoweverThe adverse effects of Hg on neurodevelopment and neurological function have been well-documented and described from relatively high-dose exposures occurring during gestation that represent effectively what could be categorized as environmental poisonings. These include the case studies illustrating the disastrous, devastating impacts in Minamata Bay, Japan, and to a lesser extent, the neurological impairments resulting from the inadvertent use of Hg-contaminated wheat in the country of Iraq ,4. There are also two large longitudinal cohort studies that have been conducted in the Seychelles in the Indian Ocean, and the Faroe Islands in the North Atlantic Ocean, along with a smaller study in New Zealand examining neurodevelopmental impacts of relatively high levels of mercury ,29,48,49At present, no systematically collected data or studies of neurodevelopment or performance on neuropsychological and neurophysiological tests are available for evaluation in Suriname. This research group, which is a partnership between investigators in Suriname and the United States, is in the process of addressing that shortcoming by measuring neurodevelopmental progress from birth through 4–5 years of age in an ongoing longitudinal cohort study of 1000 mother-child dyads. In addition, both blood  and hair mercury levels are being determined in participants in this same cohort. Systematic surveys of fish consumption, including intake rates as well as species and preferences of species consumed, are being collected to better inform assessment of health risk, and if and where necessary, facilitate the development of consumption advisories tailored to communities based on literacy levels using a culturally competent approach. Based on the previous cohort studies, it is also important that other dietary components be measured, such as omega-three fatty acids both in consumed finfish and in human participants. There is also emerging evidence that selenium may improve pediatric cognitive function, as well as protect against methylmercury toxicity ,53,54. MDespite decades of research, the effects of mercury on neurodevelopment in children below those of obvious clinical toxicity , remain a challenge to unequivocally define. This is, in large part, because neurodevelopment is an inherently complex process influenced by a number of physical, chemical, and social factors. Relatively high levels of mercury have been found in hair samples from women and children in interior areas of Suriname, as reported in this study. At present, these levels are similar to those found in previous cohort studies that have found negative neurodevelopmental impacts on children exposed during gestation and possibly during early childhood ,6,7,8,9.